Provider Demographics
NPI:1205822756
Name:FOSSEL, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FOSSEL
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 1:9464 CONSERVATION ST NE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9752
Mailing Address - Country:US
Mailing Address - Phone:616-676-8779
Mailing Address - Fax:
Practice Address - Street 1:9464 CONSERVATION ST NE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-9752
Practice Address - Country:US
Practice Address - Phone:616-676-8779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046371207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1658868Medicaid
MI0D16091001Medicare ID - Type Unspecified
MIB45449Medicare UPIN