Provider Demographics
NPI:1235220740
Name:MACDONALD, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MACDONALD
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 1:22 STATION AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2092
Mailing Address - Country:US
Mailing Address - Phone:207-373-6848
Mailing Address - Fax:207-373-6849
Practice Address - Street 1:22 STATION AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011
Practice Address - Country:US
Practice Address - Phone:207-373-6848
Practice Address - Fax:207-373-6849
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0155660207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME314110099Medicaid
MEAA228143OtherHARVARD PILGRIM
MEG52943Medicare UPIN
ME314110099Medicaid