Basic Information
| Provider Information | |||||||||
| NPI: | 1609854611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALCOTT | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38935 ANN ARBOR RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481503354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346320175 | ||||||||
| FaxNumber: | 7346320182 | ||||||||
| Practice Location | |||||||||
| Address1: | 18101 OAKWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481244089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135937000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 07/02/2013 | ||||||||
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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 | 207P00000X | 4301078051 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10-4631349 | 05 | MI | MEDICAID | 10-4631385 | 05 | MI | MEDICAID | 10-4710353 | 05 | MI | MEDICAID | 10-4631394 | 05 | MI | MEDICAID | 10-4710344 | 05 | MI | MEDICAID | 10-4631376 | 05 | MI | MEDICAID | 11311888 | 01 | MI | CAQH | OTHER | 10-4631358 | 05 | MI | MEDICAID | 10-4710335 | 05 | MI | MEDICAID |