Provider Demographics
NPI:1174730444
Name:WILSON, ELINE HAENEBALCKE (MD)
Entity type:Individual
Prefix:DR
First Name:ELINE
Middle Name:HAENEBALCKE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELINE
Other - Middle Name:
Other - Last Name:HAENEBALCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5970
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:3750 WOODWARD AVE
Practice Address - Street 2:STE 200C
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2007
Practice Address - Country:US
Practice Address - Phone:313-993-4645
Practice Address - Fax:313-993-4654
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA116814207V00000X
MI4301100277207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630840Medicare PIN