Healthcare Provider Details

I. General information

NPI: 1578148375
Provider Name (Legal Business Name): MICHIGAN MSK MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36385 HARPER AVE
CLINTON TOWNSHIP MI
48035-2958
US

IV. Provider business mailing address

36385 HARPER AVE
CLINTON TOWNSHIP MI
48035-2958
US

V. Phone/Fax

Practice location:
  • Phone: 586-684-1900
  • Fax: 586-684-1999
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID R HICKLING
Title or Position: OWNER
Credential: DO
Phone: 586-684-1900