Basic Information
| Provider Information | |||||||||
| NPI: | 1194975334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KSYCKI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1611 NW 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055851288 | ||||||||
| FaxNumber: | 3055850142 | ||||||||
| Practice Location | |||||||||
| Address1: | 1611 NW 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055851288 | ||||||||
| FaxNumber: | 3055850142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2008 | ||||||||
| LastUpdateDate: | 04/11/2011 | ||||||||
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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 | 208600000X | OS10488 | FL | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | OS10488 | FL | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 0005551-00 | 05 | FL | MEDICAID |