Provider Demographics
NPI:1114008711
Name:STEWART, MICHAEL GORDON (PHD, CCC-A)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GORDON
Last Name:STEWART
Suffix:
Gender:M
Credentials:PHD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 HEALTH PROFESSIONS BLDG
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48859-0001
Mailing Address - Country:US
Mailing Address - Phone:989-774-3904
Mailing Address - Fax:989-774-1891
Practice Address - Street 1:1101 HEALTH PROFESSIONS BLDG
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859-0001
Practice Address - Country:US
Practice Address - Phone:989-774-3904
Practice Address - Fax:989-774-1891
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000250231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1601000250OtherSTATE LICENSE
MI640C32605OtherBCBS PIN
MI00719898OtherASHA NUMBER
MI40-4683793Medicaid
MI90-2628470Medicaid
MI00719898OtherASHA NUMBER