Provider Demographics
NPI:1154478055
Name:MICHELIN, ROBERT EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:MICHELIN
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:PO BOX 2414
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-2414
Mailing Address - Country:US
Mailing Address - Phone:530-273-1914
Mailing Address - Fax:
Practice Address - Street 1:155 GLASSON WAY
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5723
Practice Address - Country:US
Practice Address - Phone:530-274-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36138208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00361380Medicaid
CA00C361381Medicare PIN
CA00361380Medicaid