Provider Demographics
NPI:1659713824
Name:CHARLES J ZICKUS DO PLC
Entity Type:Organization
Organization Name:CHARLES J ZICKUS DO PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PLC
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZICKUS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-728-5858
Mailing Address - Street 1:4045 ANTIGO CT SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3145
Mailing Address - Country:US
Mailing Address - Phone:616-532-2640
Mailing Address - Fax:
Practice Address - Street 1:1700 CLINTON ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5502
Practice Address - Country:US
Practice Address - Phone:231-728-5858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012689207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM6066075Medicare PIN