Provider Demographics
NPI:1023152147
Name:PRICE, MICHAEL T (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
Last Name:PRICE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1560 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-1914
Mailing Address - Country:US
Mailing Address - Phone:248-547-3396
Mailing Address - Fax:
Practice Address - Street 1:19401 HUBBARD DRIVE
Practice Address - Street 2:HENRY FORD HOSPITAL FAIRLAINE ER
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126
Practice Address - Country:US
Practice Address - Phone:313-982-8369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant