Provider Demographics
NPI:1326094889
Name:CHAMPAGNE, MICHELINE
Entity Type:Individual
Prefix:
First Name:MICHELINE
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 PAGE ST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:MA
Mailing Address - Zip Code:02322-1211
Mailing Address - Country:US
Mailing Address - Phone:508-427-5512
Mailing Address - Fax:
Practice Address - Street 1:999 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-3072
Practice Address - Country:US
Practice Address - Phone:781-963-1697
Practice Address - Fax:781-963-5770
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA132422251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY67978OtherBLUE CROSS BLUE SHIELD
MAY68566Medicare ID - Type Unspecified