Provider Demographics
NPI:1154412302
Name:MAGOLINE, MICHAEL R (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MAGOLINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 W BELTLINE HWY
Mailing Address - Street 2:SSM HEALTH FDLREGIONAL CLINIC ATTN: NANCY PIERCE
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2334
Mailing Address - Country:US
Mailing Address - Phone:920-926-8343
Mailing Address - Fax:
Practice Address - Street 1:421 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8335
Practice Address - Country:US
Practice Address - Phone:920-926-8616
Practice Address - Fax:920-926-8098
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-071501207X00000X
WI82106-20207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2187002Medicaid
OHH04040Medicare UPIN
OH4025499Medicare PIN