Provider Demographics
NPI:1316987142
Name:VERWILGHEN, JOHANNA JACOBA (MD)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:JACOBA
Last Name:VERWILGHEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16815 E JEFFERSON AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1923
Mailing Address - Country:US
Mailing Address - Phone:313-831-1100
Mailing Address - Fax:313-831-1177
Practice Address - Street 1:16815 E JEFFERSON AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1923
Practice Address - Country:US
Practice Address - Phone:313-831-1100
Practice Address - Fax:313-831-1177
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077528207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1108235412OtherBCBS
MI026068OtherDMC
MI026068OtherDMC
MI1108235412OtherBCBS