Basic Information
| Provider Information | |||||||||
| NPI: | 1962474163 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WESOLOWSKI | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, MHSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1304 FAWCETT AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984021900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2537614201 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 EAST MEDICAL CENTER DR | ||||||||
| Address2: | B1 FLOOR UNIVERSITY HOSPITAL RECP C | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349364566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 06/29/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301089073 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD180766 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | 4301089073 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | MD180766 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | MD60703635 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | D0063047 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD60703635 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2849 | 01 | MD | B/C B/S | OTHER | J062 | 01 | MD | B/C B/S | OTHER | KA80 | 01 | MD | B/C B/S | OTHER | 407969800 | 05 | MD | MEDICAID |