Healthcare Provider Details

I. General information

NPI: 1871595504
Provider Name (Legal Business Name): MICHAEL ANDREW BRESTICKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MIKE BRESTICKER M.D.

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-3361
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6367
  • Fax: 570-271-7142
Mailing address:
  • Phone: 570-271-6144
  • Fax: 570-271-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01048626A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number55608-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036-079877
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD049632L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: