Provider Demographics
NPI:1730347808
Name:TODD STANISZEWSKI OD PC
Entity type:Organization
Organization Name:TODD STANISZEWSKI OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:HURST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-620-1100
Mailing Address - Street 1:5874 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3358
Mailing Address - Country:US
Mailing Address - Phone:248-620-1100
Mailing Address - Fax:248-620-1196
Practice Address - Street 1:5874 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3358
Practice Address - Country:US
Practice Address - Phone:248-620-1100
Practice Address - Fax:248-620-1196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003704305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M41550Medicare PIN
MI1190300001Medicare NSC
MIU54520Medicare UPIN