1710390562 NPI number — MICHAEL JOHN WILD MS, ATC, PES

Table of content: MICHAEL JOHN WILD MS, ATC, PES (NPI 1710390562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710390562 NPI number — MICHAEL JOHN WILD MS, ATC, PES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILD
Provider First Name:
MICHAEL
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, ATC, PES
Provider Gender Code:
M

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:
1710390562
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5963 ROUTE 98
Provider Second Line Business Mailing Address:
PO BOX 7
Provider Business Mailing Address City Name:
GREAT VALLEY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14741-0007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-969-7581
Provider Business Mailing Address Fax Number:
716-566-7858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4380 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMHERST
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14226-3544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-839-8581
Provider Business Practice Location Address Fax Number:
716-566-7858
Provider Enumeration Date:
06/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  7952261 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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