1023265675 NPI number — MRS. MICHELLE MARIE MCDONALD PT

Table of content: MRS. MICHELLE MARIE MCDONALD PT (NPI 1023265675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023265675 NPI number — MRS. MICHELLE MARIE MCDONALD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDONALD
Provider First Name:
MICHELLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023265675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 STANMOOR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48329-2364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-674-9556
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44555 WOODWARD AVE
Provider Second Line Business Practice Location Address:
SUITE 080
Provider Business Practice Location Address City Name:
PONTIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48341-5031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-858-6950
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5501003410 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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