1043352701 NPI number — PETER M LISIECKI PHD PC INC

Table of content: (NPI 1043352701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043352701 NPI number — PETER M LISIECKI PHD PC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETER M LISIECKI PHD PC INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043352701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7960 GRAND RIVER RD STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIGHTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48114-7335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7960 W. GRAND RIVER
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
BRIGHTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48114-7335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-227-1999
Provider Business Practice Location Address Fax Number:
810-225-2265
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LISIECKI
Authorized Official First Name:
PETER
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
810-227-1999

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  6301003173 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 680D745030 . This is a "BCBSM PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 045199 . This is a "VALUE OPTIONS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com