Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RC0200X | Critical Care Medicine | 4301052876 | MI |
N | 207RP1001X | Pulmonary Disease | 4301052876 | MI |
NPI | 1033226097 |
---|---|
Provider Name | Jeffrey L Wilt |
First Address | Kalamazoo, MI 49008-1282 |
Second Address | Kalamazoo, MI 49008-1282 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2006 |
Last Update Date | 02/04/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0C97618 | BCBS (01) | MI |
1033226097 | (05) | MI |
2904118571 | BCBS OF MICHIGAN (01) | MI |
3161767 | (05) | MI |
F22196 | (02) |