Provider Demographics
NPI:1346422862
Name:MICHAEL J MOUTSATSON DO PLLC
Entity Type:Organization
Organization Name:MICHAEL J MOUTSATSON DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MOUTSATSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:989-953-9777
Mailing Address - Street 1:2890 HEALTH PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2961
Mailing Address - Country:US
Mailing Address - Phone:989-953-9777
Mailing Address - Fax:
Practice Address - Street 1:2890 HEALTH PARKWAY
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2961
Practice Address - Country:US
Practice Address - Phone:989-953-9777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMM014511207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5370114OtherBLUE CROSS BLUE SHIELD
MI4775590Medicaid
MI0P20460Medicare PIN