Provider Demographics
NPI:1104046101
Name:PIERCE, MICHAEL (ORTHOTIST AND PROSTH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:PIERCE
Suffix:
Gender:M
Credentials:ORTHOTIST AND PROSTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 N MILLEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-3810
Mailing Address - Country:US
Mailing Address - Phone:706-549-9709
Mailing Address - Fax:
Practice Address - Street 1:590 N MILLEDGE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-3810
Practice Address - Country:US
Practice Address - Phone:706-549-9709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0000261744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000913503AMedicaid
GA1325080001Medicare NSC