Provider Demographics
NPI:1003886342
Name:MICHAELSON, JEFFEREY E (MD)
Entity Type:Individual
Prefix:
First Name:JEFFEREY
Middle Name:E
Last Name:MICHAELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18444 N 25TH AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1261
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:SUITE 401
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066261207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4337650Medicaid
MIG90456Medicare UPIN
MIP35120160Medicare PIN
MIF36278007Medicare PIN