Healthcare Provider Details

I. General information

NPI: 1811088552
Provider Name (Legal Business Name): MICHAEL JOSILEVICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 COUNTRY CLUB RD
JACKSONVILLE NC
28546-6005
US

IV. Provider business mailing address

317 HARVEST DR
JACKSONVILLE NC
28540-3812
US

V. Phone/Fax

Practice location:
  • Phone: 910-346-5016
  • Fax:
Mailing address:
  • Phone: 910-478-0730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9500962
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: