1457596223 NPI number — WELLNESS FAMILY PRACTICE P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457596223 NPI number — WELLNESS FAMILY PRACTICE P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLNESS FAMILY PRACTICE P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457596223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1003 WOODSIDE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ESSEXVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48732-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-892-7722
Provider Business Mailing Address Fax Number:
989-892-7455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2110 16TH ST
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
BAY CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48708-7609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-892-7722
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BERNER
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CLINIC ADMINISTRATOR
Authorized Official Telephone Number:
989-892-7722

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1457596223 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080Z901190 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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