Provider Demographics
NPI:1427032150
Name:JACEWICZ, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JACEWICZ
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 1:6325 HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120
Mailing Address - Country:US
Mailing Address - Phone:901-522-7700
Mailing Address - Fax:901-522-2600
Practice Address - Street 1:1211 UNION AVE
Practice Address - Street 2:STE 200
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-6638
Practice Address - Country:US
Practice Address - Phone:901-259-5340
Practice Address - Fax:901-259-5300
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD222232084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3067379Medicaid
TN3067379Medicare PIN
TN3067379Medicaid