Basic Information
| Provider Information | |||||||||
| NPI: | 1427372192 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRED WURSTER DO PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 999362 PO BOX 33738 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482323738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107205715 | ||||||||
| FaxNumber: | 8107320891 | ||||||||
| Practice Location | |||||||||
| Address1: | 1257 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LAPEER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484461346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106607902 | ||||||||
| FaxNumber: | 8106607904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2010 | ||||||||
| LastUpdateDate: | 07/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | WURSTER | ||||||||
| AuthorizedOfficialFirstName: | FRED | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8106607902 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101009054 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080D400470 | 01 | MI | BCBSM/BCN | OTHER |