Provider Demographics
NPI:1598219404
Name:MCKISSIC, JAMES ERICK
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ERICK
Last Name:MCKISSIC
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 1:14436 E JEFFERSON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2925
Mailing Address - Country:US
Mailing Address - Phone:313-933-3737
Mailing Address - Fax:
Practice Address - Street 1:14436 E JEFFERSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2925
Practice Address - Country:US
Practice Address - Phone:313-933-3737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies