Basic Information
| Provider Information | |||||||||
| NPI: | 1689640831 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ZMIEJKO | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 COMMERCE DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480593819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103854441 | ||||||||
| FaxNumber: | 8103851540 | ||||||||
| Practice Location | |||||||||
| Address1: | 4154 RIVER RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | EAST CHINA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480542925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103296710 | ||||||||
| FaxNumber: | 8103298790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 04/08/2011 | ||||||||
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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 | 208000000X | 4301042415 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1689640831 | 05 | MI | MEDICAID |