Basic Information
| Provider Information | |||||||||
| NPI: | 1306256649 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIKORSKI | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | NICHOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HULL | ||||||||
| OtherFirstName: | AMBER | ||||||||
| OtherMiddleName: | NICHOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 35054 23 MILE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | NEW BALTIMORE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480472019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867252670 | ||||||||
| FaxNumber: | 5867253347 | ||||||||
| Practice Location | |||||||||
| Address1: | 22201 MOROSS RD | ||||||||
| Address2: | PB2 STE 70 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482362169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133433800 | ||||||||
| FaxNumber: | 3133434756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2014 | ||||||||
| LastUpdateDate: | 05/29/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 5101021071 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 5101021071 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.