MEDICARE: ROGER MAILLEFER M.D.

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	208600000X	Surgery Physician	4301503936	MI
2	208600000X	Surgery Physician	036-098042	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	040142	OTHER	IL	HEALTH ALLIANCE

General Provider Information

NPI Number	:	1558373696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER MAILLEFER M.D.

Provider Business Mailing Address
First Line	:	14695 PARK AVE
Second Line	:	STE A
City	:	CHARLEVOIX
State	:	MI
Zip	:	49720-1920
Country	:	US
Telephone Number	:	815-758-8671
Fax Number	:

Provider Business Practice Location Address
First Line	:	14695 PARK AVE STE A
Second Line	:
City	:	CHARLEVOIX
State	:	MI
Zip	:	49720-1920
Country	:	US
Telephone Number	:	231-547-2812
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	12/12/2025

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