Basic Information
| Provider Information | |||||||||
| NPI: | 1316203102 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WYANDOTTE PHYSICIAN PRACTICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DOWNRIVER INTERNIST PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1640 FORT STREET | ||||||||
| Address2: | SUITE D ATTN DENISE | ||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343913057 | ||||||||
| FaxNumber: | 7343913052 | ||||||||
| Practice Location | |||||||||
| Address1: | 15450 NORTHLINE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342243679 | ||||||||
| FaxNumber: | 7342879926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2012 | ||||||||
| LastUpdateDate: | 06/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | BUDD | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR PHYSICIAN PRACTICES | ||||||||
| AuthorizedOfficialTelephone: | 7343913057 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301048664 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.