Provider Demographics
NPI:1518438860
Name:BRYCZKOWSKI, MAREK
Entity Type:Individual
Prefix:
First Name:MAREK
Middle Name:
Last Name:BRYCZKOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40429 SHAKESPEARE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-4154
Mailing Address - Country:US
Mailing Address - Phone:586-596-3228
Mailing Address - Fax:
Practice Address - Street 1:12900 HALL RD STE 200
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1150
Practice Address - Country:US
Practice Address - Phone:586-801-3294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist