Basic Information
| Provider Information | |||||||||
| NPI: | 1376541441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDER ROEST | ||||||||
| FirstName: | WILFRED | ||||||||
| MiddleName: | LEWIS | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4201 CAMPUS RIDGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894885450 | ||||||||
| FaxNumber: | 9894885455 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 CAMPUS RIDGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894885450 | ||||||||
| FaxNumber: | 9894885455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 11/02/2016 | ||||||||
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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 | 207RC0200X | 5101007653 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 5101007653 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 4218130 | 05 | MI | MEDICAID |