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General NPI Number Information
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NPI Number | 1528492212
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Entity Type | Organization
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Legal Business Name | JERRY A DANCIK
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Dates
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Enumeration Date | 08/29/2013
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Last Update Date | 12/12/2013
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Provider Practice Location Address
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Address Line | 1455 S LAPEER RD SUITE 207
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City | LAKE ORION
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State | MI
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Zip | 48360-1467
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Country | US
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Telephone | 248-690-9946
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Fax | 248-690-9956
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Provider Business Mailing Address
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Address Line | 1455 S LAPEER RD SUITE 207
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City | LAKE ORION
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State | MI
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Zip | 48360-1467
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Country | US
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Telephone | 248-690-9946
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Fax | 248-690-9956
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Authorized Official
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Title or Position | CEO
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Name | DR. JERRY ALLEN DANCIK
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Credential | M.D.
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Telephone | 248-690-9946
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 4301033510
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License Number State | MI
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