Provider Demographics
NPI:1588774566
Name:WAGENHEIM, ELLIOT CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:CHARLES
Last Name:WAGENHEIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 N OLD WOODWARD AVE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-5300
Mailing Address - Country:US
Mailing Address - Phone:248-642-8330
Mailing Address - Fax:248-642-6630
Practice Address - Street 1:280 N OLD WOODWARD AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-5300
Practice Address - Country:US
Practice Address - Phone:248-642-8330
Practice Address - Fax:248-642-6630
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010351352084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE25844Medicare UPIN