Provider Demographics
NPI:1871595504
Name:BRESTICKER, MICHAEL ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:BRESTICKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:BRESTICKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-3361
Practice Address - Country:US
Practice Address - Phone:570-271-6367
Practice Address - Fax:570-271-7142
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048626A208G00000X
WI55608-20208G00000X
IL036-079877208G00000X
PAMD049632L208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079877Medicaid
MI1871595504Medicaid
IN200183480EMedicaid
IN200183480AMedicaid
IN200183480CMedicaid
IN200183480DMedicaid
IN200183480BMedicaid
IN200183480AMedicaid
IN200183480BMedicaid
IN780002116Medicare PIN
ILK17114Medicare PIN
ILL78988Medicare PIN
ILG23942Medicare UPIN
IN200183480DMedicaid
IN200183480EMedicaid