Provider Demographics
NPI:1487629085
Name:WICHLACZ, ROBERT (MPT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WICHLACZ
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3041 CHARLEVOIX DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7035
Mailing Address - Country:US
Mailing Address - Phone:616-942-7200
Mailing Address - Fax:
Practice Address - Street 1:3041 CHARLEVOIX DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7035
Practice Address - Country:US
Practice Address - Phone:616-942-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006967208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650G011440OtherBOB BCBSMI
MI5501006967OtherBOB STATE
MI5501006967OtherBOB STATE