MEDICARE: MARCO K MICHELSON MD

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	207RI0200X	Infectious Disease Physician	188110	NY

General Provider Information

NPI Number	:	1770735920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCO K MICHELSON MD

Provider Business Mailing Address
First Line	:	PO BOX 766
Second Line	:
City	:	PORT WASHINGTON
State	:	NY
Zip	:	11050-0766
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1051 PORT WASHINGTON BLVD
Second Line	:	NO. 766
City	:	PORT WASHINGTON
State	:	NY
Zip	:	11050-2941
Country	:	US
Telephone Number	:	917-771-2111
Fax Number	:

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

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	04/09/2009

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