Healthcare Provider Details

I. General information

NPI: 1194168005
Provider Name (Legal Business Name): MICHAEL MAKSIMOWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2013
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST
DETROIT MI
48201
US

IV. Provider business mailing address

4646 JOHN R ST RM B2340
DETROIT MI
48201-1916
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-1000
  • Fax: 313-966-1195
Mailing address:
  • Phone: 313-576-1000
  • Fax: 313-966-1195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number4301114125
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301114125
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: