Provider Demographics
NPI:1346249919
Name:MONTICO, MICHAEL PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
Last Name:MONTICO
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 1:1050 CORPORATE OFFICE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-3199
Mailing Address - Country:US
Mailing Address - Phone:248-684-6155
Mailing Address - Fax:248-684-6154
Practice Address - Street 1:1050 CORPORATE OFFICE DR STE 100
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-3199
Practice Address - Country:US
Practice Address - Phone:248-684-6155
Practice Address - Fax:248-684-6154
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072084207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI440244410Medicaid
MI0F36020099Medicare ID - Type Unspecified
MIH62075Medicare UPIN