Provider Demographics
NPI:1861481392
Name:PAVLIK, MICHELLE L (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:PAVLIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21700 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1604
Mailing Address - Country:US
Mailing Address - Phone:734-671-8660
Mailing Address - Fax:734-671-9177
Practice Address - Street 1:21700 ALLEN RD
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-1604
Practice Address - Country:US
Practice Address - Phone:734-671-8660
Practice Address - Fax:734-671-9177
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080096208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4773344Medicaid