Provider Demographics
NPI:1902137920
Name:GORECKI, ANDREW CHARLES (PT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:CHARLES
Last Name:GORECKI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 EASTERN SKY DR STE 6
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7351
Mailing Address - Country:US
Mailing Address - Phone:231-932-9014
Mailing Address - Fax:231-932-9034
Practice Address - Street 1:3899 W FRONT ST
Practice Address - Street 2:UNIT 3
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8103
Practice Address - Country:US
Practice Address - Phone:231-932-9014
Practice Address - Fax:231-932-9034
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4797005Medicaid
MI0B81315OtherBLUE CROSS BLUE SHIELD MI