Basic Information
| Provider Information | |||||||||
| NPI: | 1104851658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISNIEWSKI | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 271 MCCOY RD W | ||||||||
| Address2: | |||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497358253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897317708 | ||||||||
| FaxNumber: | 9897317929 | ||||||||
| Practice Location | |||||||||
| Address1: | 829 N CENTER AVE | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497351595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897317870 | ||||||||
| FaxNumber: | 9897317837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 06/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 430150548 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 4301050548 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 381303843 | 01 | TAX ID | OTHER | 4619513 | 05 | MI | MEDICAID | 11292239 | 01 | CAQH PROVIDER ID | OTHER | 0F96004016 | 01 | MI | MEDICARE PTAN | OTHER | 1101507782 | 01 | MI | BCBSM PROVIDER NUMBER | OTHER | CC4805 | 01 | MEDICARE RR PROV ID | OTHER |