Provider Demographics
NPI: | 1952675670 |
---|---|
Name: | M MAUREAU DO PLLC |
Entity Type: | Organization |
Organization Name: | M MAUREAU DO PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MICHELLE |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | MAUREAU |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DO |
Authorized Official - Phone: | 810-820-9438 |
Mailing Address - Street 1: | 3171 MOMENTUM PL |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60689-5331 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 810-720-5715 |
Mailing Address - Fax: | 810-732-0891 |
Practice Address - Street 1: | 8382 HOLLY RD |
Practice Address - Street 2: | STE 2 |
Practice Address - City: | GRAND BLANC |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48439-1971 |
Practice Address - Country: | US |
Practice Address - Phone: | 810-820-9438 |
Practice Address - Fax: | 810-820-9456 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-02-27 |
Last Update Date: | 2012-11-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 5101012819 | 208D00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Single Specialty |