Provider Demographics
NPI:1194830984
Name:BRISKI, LAURENCE E (MD)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:E
Last Name:BRISKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-4000
Practice Address - Fax:313-881-4727
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI041875207ZM0300X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZM0300XAllopathic & Osteopathic PhysiciansPathologyMedical Microbiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4618202Medicaid
N94390002Medicare ID - Type Unspecified
B48893Medicare UPIN