=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124385323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DONALD MICHAEL, MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2012
-----------------------------------------------------
Last Update Date | 04/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 E MISHAWAKA AVE
-----------------------------------------------------
City | MISHAWAKA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46545-6602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-254-0103
-----------------------------------------------------
Fax | 574-254-0119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 E MISHAWAKA AVE
-----------------------------------------------------
City | MISHAWAKA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46545-6602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-254-0103
-----------------------------------------------------
Fax | 574-254-0119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. DONALD JOSEPH MICHAEL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 574-254-0103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 01034859
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------