Provider Demographics
NPI:1992250195
Name:MICHAEL A WAGNER PLLC
Entity type:Organization
Organization Name:MICHAEL A WAGNER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-469-8300
Mailing Address - Street 1:21620 HARRINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-2319
Mailing Address - Country:US
Mailing Address - Phone:586-469-8300
Mailing Address - Fax:586-469-1372
Practice Address - Street 1:21620 HARRINGTON ST
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-2319
Practice Address - Country:US
Practice Address - Phone:586-469-8300
Practice Address - Fax:586-469-1372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018806207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty