Basic Information
| Provider Information | |||||||||
| NPI: | 1447313986 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHIANA SLEEP & PULMONARY ASSOCIATES P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3904 STONEGATE PARK | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699825864 | ||||||||
| FaxNumber: | 2699825113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3904 STONEGATE PARK | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699825864 | ||||||||
| FaxNumber: | 2699825113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PIASECKI | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2699825864 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 5101008659 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207RS0012X | 5101008659 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 363AM0700X | 5601004477 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207RP1001X | 5101008659 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 115110074 | 01 | MI | BCBSM | OTHER |