Provider Demographics
NPI:1700048832
Name:MARCO K MICHELSON, MD, PC
Entity Type:Organization
Organization Name:MARCO K MICHELSON, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:K
Authorized Official - Last Name:MICHELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-771-2111
Mailing Address - Street 1:PO BOX 766
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-0766
Mailing Address - Country:US
Mailing Address - Phone:917-771-2111
Mailing Address - Fax:
Practice Address - Street 1:1051 PORT WASHINGTON BLVD
Practice Address - Street 2:NO 766
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-2941
Practice Address - Country:US
Practice Address - Phone:917-771-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188110207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01366912Medicaid
NY18G081Medicare PIN
NY01366912Medicaid