Healthcare Provider Details

I. General information

NPI: 1801966122
Provider Name (Legal Business Name): THEODORE FITCH MAUGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 THORNAPPLE RIVER DR SE
GRAND RAPIDS MI
49546-9736
US

IV. Provider business mailing address

1325 THORNAPPLE RIVER DR SE
GRAND RAPIDS MI
49546-9736
US

V. Phone/Fax

Practice location:
  • Phone: 616-676-0208
  • Fax:
Mailing address:
  • Phone: 616-676-0208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301039223
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: