Healthcare Provider Details

I. General information

NPI: 1043297955
Provider Name (Legal Business Name): ANDREW JAMES STASEVICH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 HASLETT RD
HASLETT MI
48840-7615
US

IV. Provider business mailing address

3955 PATIENT CARE DR STE A
LANSING MI
48911-4271
US

V. Phone/Fax

Practice location:
  • Phone: 517-339-3200
  • Fax:
Mailing address:
  • Phone: 517-374-7600
  • Fax: 855-495-5457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101013062
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: