Provider Demographics
NPI:1104894179
Name:CEROVSKI, JOHN THOMAS (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:CEROVSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 JOHN ST
Mailing Address - Street 2:STE. 103
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-2870
Mailing Address - Country:US
Mailing Address - Phone:269-345-8626
Mailing Address - Fax:269-345-3032
Practice Address - Street 1:820 JOHN ST
Practice Address - Street 2:STE. 103
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-2870
Practice Address - Country:US
Practice Address - Phone:269-345-8626
Practice Address - Fax:269-345-3032
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034602207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI03976370112Medicare ID - Type Unspecified
MIB44095Medicare UPIN