Healthcare Provider Details

I. General information

NPI: 1992866784
Provider Name (Legal Business Name): MICHAEL JOSEPH MAGGIO PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BRADFORD ST NE
GRAND RAPIDS MI
49525-6427
US

IV. Provider business mailing address

PO BOX 1687
GRAND RAPIDS MI
49501-1687
US

V. Phone/Fax

Practice location:
  • Phone: 616-885-5000
  • Fax: 616-885-5020
Mailing address:
  • Phone: 616-486-9280
  • Fax: 616-974-9064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0002740
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601005545
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005545
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: