Provider Demographics
NPI:1124006333
Name:VITALE, MASSIMILIANO P (MD)
Entity Type:Individual
Prefix:
First Name:MASSIMILIANO
Middle Name:P
Last Name:VITALE
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 1:17900 23 MILE RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1161
Mailing Address - Country:US
Mailing Address - Phone:586-868-9800
Mailing Address - Fax:586-868-9801
Practice Address - Street 1:17900 23 MILE RD
Practice Address - Street 2:SUITE 303
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1161
Practice Address - Country:US
Practice Address - Phone:586-868-9800
Practice Address - Fax:586-868-9801
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076839207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700E031610OtherBCBSM GROUP PIN
MII15040Medicare UPIN
MIMI3971028Medicare PIN
MIN40170058Medicare PIN
MIN40170058Medicare ID - Type UnspecifiedMEDICARE
MI4952766Medicaid