Provider Demographics
NPI:1609808203
Name:MACGREGOR, MICHAEL M (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:MACGREGOR
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-2111
Mailing Address - Fax:215-707-2324
Practice Address - Street 1:3401 N. BROAD ST.
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140
Practice Address - Country:US
Practice Address - Phone:215-707-2111
Practice Address - Fax:215-707-2324
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051136363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA096784Medicare ID - Type Unspecified
PAP76115Medicare UPIN