MEDICARE: MICHAEL LICHOMSKI

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1659175495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL LICHOMSKI

Provider Business Mailing Address
First Line	:	6720 LEYTONSTONE BLVD
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-1295
Country	:	US
Telephone Number	:	248-821-0363
Fax Number	:

Provider Business Practice Location Address
First Line	:	8431 FREDERICKSBURG RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3392
Country	:	US
Telephone Number	:	210-230-6799
Fax Number	:

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

Provider Enumeration Date	:	04/02/2025
Last Update Date	:	04/11/2025

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