=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619986213
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL JOSEPH CHARBONEAU JR. DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 11/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 730 N MACOMB ST SUITE 329
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48162-2900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-240-5860
-----------------------------------------------------
Fax | 734-240-5899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 SEAGATE # 800
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43604-1558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-585-1983
-----------------------------------------------------
Fax | 419-824-7359
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 5101010247
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------