Basic Information
Provider Information | |||||||||
NPI: | 1205856390 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ADAMCZYK | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | ARTHUR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 67000 | ||||||||
Address2: | DEPT 272801 | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482672728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5178417490 | ||||||||
FaxNumber: | 5178416917 | ||||||||
Practice Location | |||||||||
Address1: | 1401 W NORTH ST | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | MI | ||||||||
PostalCode: | 492023135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5177822555 | ||||||||
FaxNumber: | 5177823399 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2006 | ||||||||
LastUpdateDate: | 12/09/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | BA049098 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0120158 | 01 |   | PHYSICIAN HEALTH PLAN | OTHER | 1788719 | 05 | MI |   | MEDICAID | 0153800145 | 01 | MI | BCBSM | OTHER |