Basic Information
| Provider Information | |||||||||
| NPI: | 1164490611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14700 LAKE SHORE DRIVE | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315474024 | ||||||||
| FaxNumber: | 2315478088 | ||||||||
| Practice Location | |||||||||
| Address1: | 14651 W UPRIGHT ST | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315474477 | ||||||||
| FaxNumber: | 2315474753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 65787 | MN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 4301067907 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 4197610 | 05 | MI | MEDICAID | 160055213 | 01 | MI | RR MEDICARE | OTHER | 160B41011 | 01 | MI | BCBS MI | OTHER | 383445481 | 01 | MI | TAX ID | OTHER |