Healthcare Provider Details

I. General information

NPI: 1376121350
Provider Name (Legal Business Name): AARON TISACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39450 W TWELVE MILE RD
NOVI MI
48377-3600
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 248-344-6688
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301518000
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: