Provider Demographics
NPI:1366479040
Name:CIESLAK, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:CIESLAK
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 1:19401 HUBBARD DRIVE
Mailing Address - Street 2:SUITE 207 HENRY FORD HEALTH SYSTEM
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126
Mailing Address - Country:US
Mailing Address - Phone:313-982-8261
Mailing Address - Fax:
Practice Address - Street 1:19401 HUBBARD DRIVE
Practice Address - Street 2:SUITE 207 HENRY FORD HEALTH SYSTEM
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126
Practice Address - Country:US
Practice Address - Phone:313-982-8261
Practice Address - Fax:313-982-8205
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010161508207P00000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RC061508OtherCHAMPUS-CHAMPUS
OH2378930Medicaid
RC061508OtherCOMMERCIAL-COMMERCIAL NUMBER
OHG56900Medicare UPIN
OH2378930Medicaid