Provider Demographics
NPI:1750887436
Name:GEORGIA, MICHELLE ANNE (DO)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANNE
Last Name:GEORGIA
Suffix:
Gender:F
Credentials:DO
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Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-442-2599
Practice Address - Fax:774-443-2062
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2024-06-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA10182272080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110136328AMedicaid