Provider Demographics
NPI:1902061799
Name:WANSOM MEDICAL CENTER, P.C.
Entity Type:Organization
Organization Name:WANSOM MEDICAL CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHATE
Authorized Official - Middle Name:
Authorized Official - Last Name:WANSOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-242-3060
Mailing Address - Street 1:1492 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-4210
Mailing Address - Country:US
Mailing Address - Phone:734-242-3060
Mailing Address - Fax:734-242-3062
Practice Address - Street 1:1492 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4210
Practice Address - Country:US
Practice Address - Phone:734-242-3060
Practice Address - Fax:734-242-3062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038906208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1395936Medicaid
MI0580012OtherBCBS
MI1395936Medicaid