Healthcare Provider Details

I. General information

NPI: 1952247561
Provider Name (Legal Business Name): DEREK RAY MAIKOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28477 HOOVER RD
WARREN MI
48093-5400
US

IV. Provider business mailing address

28477 HOOVER RD
WARREN MI
48093-5400
US

V. Phone/Fax

Practice location:
  • Phone: 586-250-4040
  • Fax:
Mailing address:
  • Phone: 586-250-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number175T00000X
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: