MEDICARE: CENTRAL MICHIGAN GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center	JM012412	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5330109	OTHER	MI	BLUE CROSS BLUE SHIELD OF MICHIGAN

General Provider Information

NPI Number	:	1124540240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL MICHIGAN GROUP

Provider Business Mailing Address
First Line	:	231 W LAKE LANSING RD STE 200
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48823-8451
Country	:	US
Telephone Number	:	517-272-0886
Fax Number	:	517-272-0887

Provider Business Practice Location Address
First Line	:	231 W LAKE LANSING RD STE 200
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48823-8451
Country	:	US
Telephone Number	:	517-272-0886
Fax Number	:	517-272-0887

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOESPH VINCENT MAURO
Credential	:	DDS
Telephone Number	:	517-272-0886

Provider Enumeration Date	:	07/11/2017
Last Update Date	:	07/21/2022

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