Provider Demographics
NPI:1174586978
Name:WILGUS, CARRIE LYNN (MD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:LYNN
Last Name:WILGUS
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 1:300 MEADOW RUN DRIVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058
Mailing Address - Country:US
Mailing Address - Phone:269-818-1020
Mailing Address - Fax:269-818-1266
Practice Address - Street 1:300 MEADOW RUN DRIVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058
Practice Address - Country:US
Practice Address - Phone:269-818-1020
Practice Address - Fax:269-818-1266
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073703174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3500800182OtherBCBS
MI4123869Medicaid