Healthcare Provider Details

I. General information

NPI: 1912908435
Provider Name (Legal Business Name): JEFFREY LEE MICH D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3790 117TH LN NW
COON RAPIDS MN
55433-2666
US

IV. Provider business mailing address

3790 117TH LN NW
COON RAPIDS MN
55433-2666
US

V. Phone/Fax

Practice location:
  • Phone: 763-421-7300
  • Fax: 763-421-3337
Mailing address:
  • Phone: 763-421-7300
  • Fax: 763-421-3337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number620
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number620
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number620
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: