MEDICARE: MICHAEL JOHN ULISSEY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	MD6023722	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366406092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL JOHN ULISSEY MD

Provider Business Mailing Address
First Line	:	1268 E MAIN ST
Second Line	:	SUITE 1
City	:	AUBURN
State	:	WA
Zip	:	98002-5748
Country	:	US
Telephone Number	:	253-735-1991
Fax Number	:	253-735-8837

Provider Business Practice Location Address
First Line	:	1268 E MAIN ST
Second Line	:	SUITE 1
City	:	AUBURN
State	:	WA
Zip	:	98002-5748
Country	:	US
Telephone Number	:	253-735-1991
Fax Number	:	253-735-8837

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2006
Last Update Date	:	09/29/2014

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