Provider Demographics
NPI:1235451311
Name:METCALFE, MICHAEL JOHN (MS, ATC, CSCS, CES)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:METCALFE
Suffix:
Gender:M
Credentials:MS, ATC, CSCS, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 FOREST AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-1505
Mailing Address - Country:US
Mailing Address - Phone:651-285-2478
Mailing Address - Fax:
Practice Address - Street 1:239 PARK AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2911
Practice Address - Country:US
Practice Address - Phone:651-285-2478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19112255A2300X
MEAT6782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEAT678OtherATHLETIC TRAINING LICENSE