Basic Information
| Provider Information | |||||||||
| NPI: | 1366433377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZICCARDI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 2420 OWEN RD | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484303417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104962500 | ||||||||
| FaxNumber: | 8106290415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101012293 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080172343 | 01 | MI | METRAHEALTH | OTHER | 253396 | 01 | MI | HEALTH ADVANTAGE NETWORK | OTHER | 080D410020 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 0852502204 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 9921034004 | 01 | MI | CIGNA | OTHER | G56808 | 01 | MI | HEALTH NET FEDERAL SERV | OTHER | G56808 | 01 | MI | HEALTH ALLIANCE PLAN | OTHER | 080D410020 | 01 | MI | COMMUNITY BLUE | OTHER | 0990939 | 01 | MI | HEALTH PLUS | OTHER | 080D410020 | 01 | MI | BLUE CARE NETWORK | OTHER | 4361486 | 05 | MI | MEDICAID | 5639565 | 01 | MI | AETNA | OTHER | C7899 | 01 | MI | MCARE | OTHER | 080D410020 | 01 | MI | BLUE CROSS POS | OTHER | 253396 | 01 | MI | MCLAREN HEALTH PLAN | OTHER |