Healthcare Provider Details

I. General information

NPI: 1275189797
Provider Name (Legal Business Name): MICHAEL LEE HUTCHISON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 EASTERN AVE
BALTIMORE MD
21224-2772
US

IV. Provider business mailing address

1434 WILLIAMSBRIDGE RD
BRONX NY
10461-2507
US

V. Phone/Fax

Practice location:
  • Phone: 410-814-4500
  • Fax:
Mailing address:
  • Phone: 718-618-0401
  • Fax: 347-479-1303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number026310
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0007700
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: