Provider Demographics
NPI:1558560862
Name:RADAWSKI, MELISSA MANZANO (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MANZANO
Last Name:RADAWSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LYNN
Other - Last Name:MANZANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8419
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M124
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-7500
Practice Address - Fax:269-341-7540
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35098127208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417961137OtherBCBSM - BRONSON
MI1558560862Medicaid
MI1417961137OtherBCBSM - BRONSON