Provider Demographics
NPI:1790854982
Name:PIASECKI, ROBERT L (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:PIASECKI
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 1:1941 S BANEY RD
Mailing Address - Street 2:STE 400
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-4502
Mailing Address - Country:US
Mailing Address - Phone:419-207-2375
Mailing Address - Fax:
Practice Address - Street 1:7916 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-432-2297
Practice Address - Fax:260-434-6481
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005488A207RP1001X, 207RS0012X
OH34.014604207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1151100074OtherBLUE CROSS BLUE SHIELD MI
MI1790854982Medicaid
MIP55547OtherBCNM INDIVIDUAL NUMBER
IN300017715Medicaid
MI1151100074OtherBLUE CROSS BLUE SHIELD MI
MI4179846Medicaid
MIP55547OtherBCNM INDIVIDUAL NUMBER