Provider Demographics
NPI:1578561304
Name:WILLIAMS, MICHAEL GREGORY (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GREGORY
Last Name:WILLIAMS
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 1:20411 W 12 MILE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-6404
Mailing Address - Country:US
Mailing Address - Phone:248-905-3194
Mailing Address - Fax:248-905-3548
Practice Address - Street 1:20411 W 12 MILE RD STE 102
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-6404
Practice Address - Country:US
Practice Address - Phone:248-905-3194
Practice Address - Fax:248-905-3548
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMW049187207P00000X
MI4301049187208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00943709OtherRAILROAD MEDICARE IND PIN
MI0108118302OtherBCBS IND
MI1578561304Medicaid
MIMI3292001Medicare PIN
MIP00943709OtherRAILROAD MEDICARE IND PIN
MIE64886Medicare UPIN