Healthcare Provider Details

I. General information

NPI: 1326183989
Provider Name (Legal Business Name): SAMUEL DYKA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E STATE ST
MONTROSE MI
48457-9144
US

IV. Provider business mailing address

7070 MILLER RD STE A
SWARTZ CREEK MI
48473-1591
US

V. Phone/Fax

Practice location:
  • Phone: 810-639-2056
  • Fax:
Mailing address:
  • Phone: 810-639-2056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001746
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: