MEDICARE: JOSHUA MADISON MACIEJEWSKI

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1801536081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSHUA MADISON MACIEJEWSKI

Provider Business Mailing Address
First Line	:	12640 STONERIDGE LN APT 204
Second Line	:
City	:	SOUTH ROCKWOOD
State	:	MI
Zip	:	48179-9555
Country	:	US
Telephone Number	:	813-579-8061
Fax Number	:

Provider Business Practice Location Address
First Line	:	12640 STONERIDGE LN APT 204
Second Line	:
City	:	SOUTH ROCKWOOD
State	:	MI
Zip	:	48179-9555
Country	:	US
Telephone Number	:	813-579-8061
Fax Number	:

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

Provider Enumeration Date	:	03/29/2022
Last Update Date	:	03/29/2022

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