Provider Demographics
NPI:1497251946
Name:FITZGERALD, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 FIDELITY ST APT D2
Mailing Address - Street 2:
Mailing Address - City:CARRBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27510-2069
Mailing Address - Country:US
Mailing Address - Phone:734-308-9341
Mailing Address - Fax:
Practice Address - Street 1:119 FIDELITY ST APT D2
Practice Address - Street 2:
Practice Address - City:CARRBORO
Practice Address - State:NC
Practice Address - Zip Code:27510-2069
Practice Address - Country:US
Practice Address - Phone:734-308-9341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2021-01334207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty