Provider Demographics
NPI:1104991207
Name:INTERNAL MEDICINE ASSOCIATES
Entity type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:WILDERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-945-2419
Mailing Address - Street 1:1005 W GREEN ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1712
Mailing Address - Country:US
Mailing Address - Phone:269-945-2419
Mailing Address - Fax:269-945-0357
Practice Address - Street 1:1005 W GREEN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1712
Practice Address - Country:US
Practice Address - Phone:269-945-2419
Practice Address - Fax:269-945-0357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICN0332OtherPALMETTO GBA RAILROAD
MI1340544Medicaid
MI0M08620014Medicare PIN
MIA77423Medicare UPIN
MI1340544Medicaid