Provider Demographics
NPI:1043280522
Name:SIWIK, JAROSLAW P (MD)
Entity Type:Individual
Prefix:
First Name:JAROSLAW
Middle Name:P
Last Name:SIWIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4828
Mailing Address - Country:US
Mailing Address - Phone:269-324-4141
Mailing Address - Fax:269-324-2020
Practice Address - Street 1:2600 W CENTRE AVE
Practice Address - Street 2:BRONSON INTERNAL MEDICINE ASSOCIATES
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4828
Practice Address - Country:US
Practice Address - Phone:269-324-4141
Practice Address - Fax:269-324-2020
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070284207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4616530Medicaid
MICA4396OtherRAILROAD MEDICARE
H71050Medicare UPIN
MIM20520037Medicare PIN