Provider Demographics
NPI:1104985001
Name:CERTIFIED EMERGENCY MEDICINE SPECIALISTS, PC
Entity type:Organization
Organization Name:CERTIFIED EMERGENCY MEDICINE SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-363-7867
Mailing Address - Street 1:PO BOX 72011
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44192-0002
Mailing Address - Country:US
Mailing Address - Phone:616-363-7867
Mailing Address - Fax:616-363-9432
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519
Practice Address - Country:US
Practice Address - Phone:616-363-7867
Practice Address - Fax:616-363-9432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9300412441OtherRAILROAD MEDICARE
MI1002854OtherCOMMUNITY HEALTH PLANS
MI1002854OtherCOMMUNITY HEALTH PLANS