Healthcare Provider Details

I. General information

NPI: 1285694448
Provider Name (Legal Business Name): MICHAEL A SIROIS MS, L-ATC, PES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SAINT ANSELMS DR BOX 1727
MANCHESTER NH
03102-1308
US

IV. Provider business mailing address

100 SAINT ANSELMS DR BOX 1727
MANCHESTER NH
03102-1308
US

V. Phone/Fax

Practice location:
  • Phone: 603-641-7807
  • Fax: 603-222-4091
Mailing address:
  • Phone: 603-641-7807
  • Fax: 603-222-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0276
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: