Provider Demographics
NPI:1619951936
Name:MAGEN, JED GARY (DO)
Entity Type:Individual
Prefix:
First Name:JED
Middle Name:GARY
Last Name:MAGEN
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:965 FEE RD ROOM A239
Mailing Address - Street 2:MICHIGAN STATE UNIVERSITY DEPARTMENT OF PSYCHIATRY
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-2893
Mailing Address - Country:US
Mailing Address - Phone:517-353-3070
Mailing Address - Fax:517-432-3603
Practice Address - Street 1:909 FEE RD ROOM B119
Practice Address - Street 2:MICHIGAN STATE UNIVERSITY DEPARTMENT OF PSYCHIATRY
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-3603
Practice Address - Country:US
Practice Address - Phone:517-353-3070
Practice Address - Fax:517-432-3603
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2012-03-12
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Provider Licenses
StateLicense IDTaxonomies
MI51010076212084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1619951936Medicaid
MI2574234Medicaid
MIC36166040Medicare PIN
MI1619951936Medicaid