Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 4301058092 | MI |
N | 208600000X | Surgeon | 4301058092 | MI |
Y | 2086S0129X | Vascular Surgeon | 4301058092 | MI |
NPI | 1013952985 |
---|---|
Provider Name | Dr. Stephen Todd Wysong |
First Address | Kalamazoo, MI 49007-5341 |
Second Address | Kalamazoo, MI 49007-5341 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2006 |
Last Update Date | 25/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
020C91020 | BCBS GRP PIN (01) | MI |
112048 | GREAT LAKES HLTH PLN (01) | |
3279453-10 | (05) | MI |
3403903000 | BCBS IND PIN (01) | MI |
5898515 | AETNA PIN (01) | |
G34768 | (02) |