Provider Demographics
NPI:1548426943
Name:FLISAK, MICHAEL THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:FLISAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3500 FRANCISCAN WAY STE 400
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-0021
Practice Address - Country:US
Practice Address - Phone:219-878-8200
Practice Address - Fax:219-877-8331
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118827207RC0000X, 207RI0011X
WI55811207RC0000X
IN02005248207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01078187OtherRR MEDICARE
IL01621208OtherBLUE CROSS BLUE SHIELD GROUP PROVIDER
IN300009476Medicaid
1508810086OtherGROUP NPI
416810012Medicare PIN
236551007Medicare PIN