Provider Demographics
NPI:1922193960
Name:METROPOLITAN MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:METROPOLITAN MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WIETRZYKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-875-9270
Mailing Address - Street 1:9230 JOSEPH CAMPAU ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3731
Mailing Address - Country:US
Mailing Address - Phone:313-875-9270
Mailing Address - Fax:313-875-9420
Practice Address - Street 1:9230 JOSEPH CAMPAU ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3731
Practice Address - Country:US
Practice Address - Phone:313-875-9270
Practice Address - Fax:313-875-9420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010814232084N0400X
MI4301063858207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110H241220OtherBCBS GROUP
MI110H241220OtherBCN GROUP
MI151659OtherGREAT LAKES HEALTH CARE
MI1922193960Medicaid
MI022808OtherMIDWEST HEALTH PLAN
MI35949OtherHEALTH PLAN OF MICHIGAN
MI5458769OtherAETNA
MI000000001426OtherCAPE HEALTH PLAN
MIDO5413OtherRAILROAD MEDICARE
MI1108269932OtherBCBS OF MICHIGAN
MIC6560OtherMCARE
MIG76852OtherHAP
MI104391529Medicaid
MI000000001426OtherCAPE HEALTH PLAN
MIG76852OtherHAP
MI1922193960Medicare PIN