1730601162 NPI number — MICHAEL WILLIAM-MULLIGAN WILLE PA-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 1730601162 NPI number — MICHAEL WILLIAM-MULLIGAN WILLE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLE
Provider First Name:
MICHAEL
Provider Middle Name:
WILLIAM-MULLIGAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1730601162
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
139 NORTHWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48307-1543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-930-9547
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17877 W 14 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEVERLY HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-644-3920
Provider Business Practice Location Address Fax Number:
248-644-2569
Provider Enumeration Date:
07/07/2017

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: 363AM0700X , with the licence number:  5601008296 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1142935 . This is a "NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS" identifier . This identifiers is of the category "OTHER".




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