Healthcare Provider Details

I. General information

NPI: 1174098214
Provider Name (Legal Business Name): MICHAEL A KRZYSKOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 COLUMBIA AVE
MUNSTER IN
46321-4008
US

IV. Provider business mailing address

730 45TH ST
MUNSTER IN
46321-2818
US

V. Phone/Fax

Practice location:
  • Phone: 121-992-4330
  • Fax: 219-934-2658
Mailing address:
  • Phone: 121-992-4330
  • Fax: 219-934-2658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number100026494A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: