Provider Demographics
NPI:1497862437
Name:MADURA, MICHAEL JAMES (MD,)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:MADURA
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1900 WEALTHY ST SE
Mailing Address - Street 2:STE 150
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2969
Mailing Address - Country:US
Mailing Address - Phone:616-459-3158
Mailing Address - Fax:616-459-4714
Practice Address - Street 1:1900 WEALTHY ST SE
Practice Address - Street 2:STE 150
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2969
Practice Address - Country:US
Practice Address - Phone:616-459-3158
Practice Address - Fax:616-459-4714
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301043486207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1004100351OtherBCBS OF MICHIGAN
MI3318794Medicaid
38-2145264OtherIRS TAX ID# THRU CORP
MI1004100351OtherBCBS OF MICHIGAN
MI0D16122013Medicare PIN