Healthcare Provider Details

I. General information

NPI: 1487863197
Provider Name (Legal Business Name): MICHAEL J MACEJKO JR. A.T.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 W 23RD ST
HAZLETON PA
18202-1646
US

IV. Provider business mailing address

1525 TERRACE BLVD
HAZLETON PA
18201-7527
US

V. Phone/Fax

Practice location:
  • Phone: 570-459-3221
  • Fax: 570-459-3139
Mailing address:
  • Phone: 570-455-0921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT000213A
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: