MEDICARE: MARCO K MICHELSON, MD, PC

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	207RI0200X	Infectious Disease Physician	188110	NY

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	:	1700048832
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARCO K MICHELSON, MD, PC

Provider Business Mailing Address
First Line	:	PO BOX 766
Second Line	:
City	:	PORT WASHINGTON
State	:	NY
Zip	:	11050-0766
Country	:	US
Telephone Number	:	917-771-2111
Fax Number	:

Provider Business Practice Location Address
First Line	:	1051 PORT WASHINGTON BLVD
Second Line	:	NO 766
City	:	PORT WASHINGTON
State	:	NY
Zip	:	11050-2941
Country	:	US
Telephone Number	:	917-771-2111
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARCO K MICHELSON
Credential	:	MD
Telephone Number	:	917-771-2111

Provider Enumeration Date	:	06/30/2008
Last Update Date	:	04/09/2009

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