1871560326 NPI number — DR. MARTIN GERARD WUNSCH PH.D.

Table of content: JALISA COVIN (NPI 1093390494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871560326 NPI number — DR. MARTIN GERARD WUNSCH PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WUNSCH
Provider First Name:
MARTIN
Provider Middle Name:
GERARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1871560326
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1728 BRENTWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48098-2630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-263-0947
Provider Business Mailing Address Fax Number:
248-267-5899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43211 DALCOMA DR
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038-6309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-263-0947
Provider Business Practice Location Address Fax Number:
248-267-5899
Provider Enumeration Date:
03/03/2006

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: 103G00000X , with the licence number:  6301005658 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 6301005658 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 6301005658 , 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: 122159 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 207862 . This is a "MANAGED HEALTH NETWORK, I" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5076046 . This is a "AETNA BEHAVIORAL HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 68OF33054 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5842 . This is a "HEALTH NET" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 071777000 . This is a "MAGELLAN HEALTH SERVICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: IP045740 . This is a "TRICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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