Healthcare Provider Details

I. General information

NPI: 1043247356
Provider Name (Legal Business Name): MICHAEL JAMES DESAVAGE MED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 INSTITUTE RD
WORCESTER MA
01609
US

IV. Provider business mailing address

15 CHATANIKA AVE
WORCESTER MA
01602
US

V. Phone/Fax

Practice location:
  • Phone: 508-831-5733
  • Fax:
Mailing address:
  • Phone: 508-397-7786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number727
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: