Basic Information
| Provider Information | |||||||||
| NPI: | 1942295373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WING | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2234 COLONIAL BLVD | ||||||||
| Address2: | ATTN: PAYER CONTRACTING & RELATIONS DEPT. | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 3650 EMERGENCY LN | ||||||||
| Address2: | |||||||||
| City: | SEBRING | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338705534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633828811 | ||||||||
| FaxNumber: | 8633826055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 06/15/2016 | ||||||||
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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 | 2085R0001X | ME0066531 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 258167100 | 05 | FL | MEDICAID | 28857 | 01 | FL | BCBS PROVIDER NUMBER | OTHER | 42196 | 01 | FL | FOUNDATION HLTH PROV. # | OTHER | 1027139 | 01 | FL | WELLCARE | OTHER | 2616613 | 01 | FL | AETNA HMO PROVIDER # | OTHER | 2660708 | 01 | FL | CIGNA | OTHER | 2734 | 01 | FL | TOTAL HLTH CH. PROV. # | OTHER | 279846 | 01 | FL | AVMED PROVIDER # | OTHER | 170074 | 01 | FL | WELLCARE PROVIDER NUMBER | OTHER | 2660708-008 | 01 | FL | CIGNA PROVIDER NUMBER | OTHER | 4934 | 01 | FL | AVMED PIN NUMBER | OTHER | 5072119 | 01 | FL | AETNA | OTHER | 920005358 | 01 | FL | RAILROAD MCR | OTHER | 4099797 | 01 | FL | GHI PROVIDER NUMBER | OTHER | 5072119 | 01 | FL | AETNA NON HMO PROVIDER # | OTHER |