Healthcare Provider Details

I. General information

NPI: 1366479040
Provider Name (Legal Business Name): RICHARD CIESLAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19401 HUBBARD DRIVE SUITE 207 HENRY FORD HEALTH SYSTEM
DEARBORN MI
48126
US

IV. Provider business mailing address

19401 HUBBARD DRIVE SUITE 207 HENRY FORD HEALTH SYSTEM
DEARBORN MI
48126
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-8261
  • Fax: 313-982-8205
Mailing address:
  • Phone: 313-982-8261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number43010161508
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number43010161508
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: