Provider Demographics
NPI:1629076294
Name:PARKER, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:PARKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 MUNSON AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3041
Mailing Address - Country:US
Mailing Address - Phone:231-933-9150
Mailing Address - Fax:231-933-1553
Practice Address - Street 1:401 MUNSON AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686
Practice Address - Country:US
Practice Address - Phone:231-933-9150
Practice Address - Fax:231-933-1553
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2018-07-11
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
MI4301056827207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1002803802OtherBCBS PROVIDER ID
MI364465889OtherTAX ID
MIP114353OtherBLUE CARE NETWORK ID
MI0N36150Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
MIC44521Medicare UPIN
MI364465889OtherTAX ID