Provider Demographics
NPI:1528492212
Name:JERRY A DANCIK
Entity type:Organization
Organization Name:JERRY A DANCIK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:DANCIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-690-9946
Mailing Address - Street 1:1455 S LAPEER RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1467
Mailing Address - Country:US
Mailing Address - Phone:248-690-9946
Mailing Address - Fax:248-690-9956
Practice Address - Street 1:1455 S LAPEER RD
Practice Address - Street 2:SUITE 207
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1467
Practice Address - Country:US
Practice Address - Phone:248-690-9946
Practice Address - Fax:248-690-9956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033510207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4218461Medicaid
MI4095853Medicaid
MIE26055Medicare UPIN
MI4095853Medicaid