Healthcare Provider Details

I. General information

NPI: 1508992041
Provider Name (Legal Business Name): MICHAEL E. STACHECKI, M.D., P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5885 S MAIN ST SUITE 3
CLARKSTON MI
48346-2981
US

IV. Provider business mailing address

5885 S MAIN ST SUITE 3
CLARKSTON MI
48346-2981
US

V. Phone/Fax

Practice location:
  • Phone: 248-620-1720
  • Fax: 248-620-1740
Mailing address:
  • Phone: 248-620-1720
  • Fax: 248-620-1740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301058225
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301058225
License Number StateMI

VIII. Authorized Official

Name: DR. MICHAEL E STACHECKI
Title or Position: OWNER--MANAGING AGENT
Credential: M.D.
Phone: 248-620-1720