Provider Demographics
NPI:1063495521
Name:MICHAELSON, JEFFREY EVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:EVAN
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 1:55 WHITCHER ST NE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1155
Mailing Address - Country:US
Mailing Address - Phone:770-422-1372
Mailing Address - Fax:770-423-9651
Practice Address - Street 1:55 WHITCHER ST NE
Practice Address - Street 2:SUITE 160
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1155
Practice Address - Country:US
Practice Address - Phone:770-422-1372
Practice Address - Fax:770-423-9651
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037623207RC0200X, 207RP1001X
GA37623207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00645147CMedicaid
2999766OtherGHI
GA202I294296OtherMEDICARE PTAN
GA290012142OtherRAILROAD MEDICARE
5341107OtherAETNA
GA58-1831482OtherFEDERAL TAX IDENTIFICATION NUMBER
GA767305OtherBLUE CROSS BLUE SHIELD
GA0932200001OtherWORKERS COMPENSATION
GA5932OtherKAISER
6054810006OtherCIGNA
4820111OtherUNITED HEALTHCARE
6054810006OtherCIGNA