Provider Demographics
NPI:1528201191
Name:MICHAEL OCCHIETTI MD PC
Entity Type:Organization
Organization Name:MICHAEL OCCHIETTI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:OCCHIETTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-779-9870
Mailing Address - Street 1:1711 S STEPHENSON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3639
Mailing Address - Country:US
Mailing Address - Phone:906-779-9870
Mailing Address - Fax:906-779-5888
Practice Address - Street 1:1711 S STEPHENSON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3639
Practice Address - Country:US
Practice Address - Phone:906-779-9870
Practice Address - Fax:906-779-5888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063234207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV32564300OtherWISC MEDICAID
MI4318832Medicaid
MI300220077OtherBLUE CROSS MI
=========OtherTAX ID
MION30910Medicare PIN
WV32564300OtherWISC MEDICAID
4326590001Medicare NSC