Provider Demographics
NPI:1366608986
Name:NOWICKI, PHILIP DANIEL (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:DANIEL
Last Name:NOWICKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 MICHIGAN ST NE
Practice Address - Street 2:SUITE 4150
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2514
Practice Address - Country:US
Practice Address - Phone:616-267-2600
Practice Address - Fax:616-267-2601
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301093641207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0390297OtherBCBS
MI1366608986Medicaid
MI0390297OtherBCBS