MEDICARE: DR. HENRYK CZESLAW PIETRUS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	HP 065997	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063445104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HENRYK CZESLAW PIETRUS M.D.

Provider Business Mailing Address
First Line	:	6940 DIXIE HWY
Second Line	:
City	:	BRIDGEPORT
State	:	MI
Zip	:	48722-9760
Country	:	US
Telephone Number	:	989-746-0933
Fax Number	:	989-746-5070

Provider Business Practice Location Address
First Line	:	6940 DIXIE HWY
Second Line	:
City	:	BRIDGEPORT
State	:	MI
Zip	:	48722-9760
Country	:	US
Telephone Number	:	989-746-0933
Fax Number	:	989-746-5070

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	11/20/2009

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