Healthcare Provider Details

I. General information

NPI: 1780667436
Provider Name (Legal Business Name): NESTOR B. HALICKI D.O.,P,C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5616 HIGHLAND RD
WATERFORD MI
48327-1926
US

IV. Provider business mailing address

5616 HIGHLAND RD
WATERFORD MI
48327-1926
US

V. Phone/Fax

Practice location:
  • Phone: 248-674-2273
  • Fax:
Mailing address:
  • Phone: 248-674-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101009374
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number5101009374
License Number StateMI

VIII. Authorized Official

Name: NESTOR HALICKI
Title or Position: PRESIDENT
Credential: D.O.
Phone: 248-674-2273