Basic Information
| Provider Information | |||||||||
| NPI: | 1164523247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILBORN | ||||||||
| FirstName: | SONALI | ||||||||
| MiddleName: | NITIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NAYAK | ||||||||
| OtherFirstName: | SONALI | ||||||||
| OtherMiddleName: | NITIN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3200 GREENFIELD RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481201802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135633332 | ||||||||
| FaxNumber: | 3135633342 | ||||||||
| Practice Location | |||||||||
| Address1: | 18181 OAKWOOD BLVD | ||||||||
| Address2: | STE 208 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481245032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132715565 | ||||||||
| FaxNumber: | 3132711053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 11/22/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301071894 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 4301071894 | MI | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RH0002X | 4301071894 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110H243080 | 01 | MI | BCBSM | OTHER | 1108294772 | 01 | MI | BCBS | OTHER | 1427297712 | 05 | MI | MEDICAID | 4535861-10 | 05 | MI | MEDICAID |