Healthcare Provider Details

I. General information

NPI: 1023637741
Provider Name (Legal Business Name): MR. MICHAEL JAMES LISIESKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 36022
GROSSE POINTE FARMS MI
48236-0022
US

IV. Provider business mailing address

PO BOX 36022
GROSSE POINTE FARMS MI
48236-0022
US

V. Phone/Fax

Practice location:
  • Phone: 419-383-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.148139
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: