Provider Demographics
NPI:1992866784
Name:MAGGIO, MICHAEL JOSEPH (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:MAGGIO
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1687
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1687
Mailing Address - Country:US
Mailing Address - Phone:616-486-9280
Mailing Address - Fax:616-974-9064
Practice Address - Street 1:2900 BRADFORD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6427
Practice Address - Country:US
Practice Address - Phone:616-885-5000
Practice Address - Fax:616-885-5020
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002740363AM0700X
MI5601005545363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1992866784Medicaid
MID17643115Medicare PIN