Healthcare Provider Details

I. General information

NPI: 1619951936
Provider Name (Legal Business Name): JED GARY MAGEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FEE RD ROOM B119 MICHIGAN STATE UNIVERSITY DEPARTMENT OF PSYCHIATRY
EAST LANSING MI
48824-3603
US

IV. Provider business mailing address

965 FEE RD ROOM A239 MICHIGAN STATE UNIVERSITY DEPARTMENT OF PSYCHIATRY
EAST LANSING MI
48824-2893
US

V. Phone/Fax

Practice location:
  • Phone: 517-353-3070
  • Fax: 517-432-3603
Mailing address:
  • Phone: 517-353-3070
  • Fax: 517-432-3603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101007621
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number5101007621
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: