Healthcare Provider Details

I. General information

NPI: 1982990289
Provider Name (Legal Business Name): PAULINE CICHON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22972 LAHSER RD
SOUTHFIELD MI
48033-4408
US

IV. Provider business mailing address

17187 SCHAEFER HWY
DETROIT MI
48235-4132
US

V. Phone/Fax

Practice location:
  • Phone: 248-353-0079
  • Fax: 248-809-6566
Mailing address:
  • Phone: 313-367-2767
  • Fax: 313-367-2818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5101020151
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: