1235451311 NPI number — MICHAEL JOHN METCALFE MS, ATC, CSCS, CES

Table of content: MICHAEL JOHN METCALFE MS, ATC, CSCS, CES (NPI 1235451311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235451311 NPI number — MICHAEL JOHN METCALFE MS, ATC, CSCS, CES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
METCALFE
Provider First Name:
MICHAEL
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, ATC, CSCS, CES
Provider Gender Code:
M

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:
1235451311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 FOREST AVE STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04101-1505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-285-2478
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
239 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04102-2911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-285-2478
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/17/2010

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: 2255A2300X , with the licence number:  1911 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2255A2300X , with the licence number: AT678 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AT678 . This is a "ATHLETIC TRAINING LICENSE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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