Healthcare Provider Details

I. General information

NPI: 1841344702
Provider Name (Legal Business Name): MICHIANA REGIONAL SLEEP DISORDERS CENTER P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3902 STONEGATE PARK
SAINT JOSEPH MI
49085-9130
US

IV. Provider business mailing address

3902 STONEGATE PARK
SAINT JOSEPH MI
49085-9130
US

V. Phone/Fax

Practice location:
  • Phone: 269-983-3690
  • Fax: 269-982-5101
Mailing address:
  • Phone: 269-983-3690
  • Fax: 269-982-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number5101008659
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number4301070920
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number5101009750
License Number StateMI

VIII. Authorized Official

Name: ROBERT L. PIASECKI
Title or Position: PRESIDENT
Credential: DO
Phone: 269-983-3690