Provider Demographics
NPI:1760179758
Name:MCMICHAEL, MATT (CSFA)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:MCMICHAEL
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1182 OLD PENDERGRASS RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-2763
Mailing Address - Country:US
Mailing Address - Phone:541-525-2829
Mailing Address - Fax:
Practice Address - Street 1:5445 MERIDIAN MARK RD STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4755
Practice Address - Country:US
Practice Address - Phone:404-459-1875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA167967246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant