Provider Demographics
NPI:1699902239
Name:WIENER, MICHELLE ANNETTE (MD,)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ANNETTE
Last Name:WIENER
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 1:12 LAKE COURT
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230
Mailing Address - Country:US
Mailing Address - Phone:248-943-4934
Mailing Address - Fax:
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:ST JOHN
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-7378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301099850207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine