Basic Information
| Provider Information | |||||||||
| NPI: | 1821079666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WURSTER | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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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: | 11/09/2005 | ||||||||
| LastUpdateDate: | 07/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101009054 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4120736 | 01 | MI | AETNA | OTHER | 0801173750 | 01 | MA | METRAHEALTH | OTHER | 080D400470 | 01 | MI | BCBSM/BCN | OTHER | 201554 | 01 | MI | MCLAREN HEALTH PLAN | OTHER | 080D400470 | 01 | MI | BCBSM | OTHER | 080D410020 | 01 | MI | BLUE CHOICE POS | OTHER | 080D410020 | 01 | MA | BLUE CARE NETWORK | OTHER | 080D410020 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 0854407884 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 201554 | 01 | MI | HEALTH ADVANTAGE NETWORK | OTHER | E25880 | 01 | MI | HEALTH ALLIANCE PLAN | OTHER | E25880 | 01 | MI | HEALTH NET FEDERAL | OTHER | 080D410020 | 01 | MI | COMMUNITY BLUE | OTHER | 4651047 | 05 | MA | MEDICAID | C2596 | 01 | MI | MCARE | OTHER |