Provider Demographics
NPI:1780889576
Name:PUSKARICH, MICHAEL ALEXANDER (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALEXANDER
Last Name:PUSKARICH
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 1:2500 N STATE ST
Mailing Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:704-807-0368
Mailing Address - Fax:601-984-5583
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC140937207P00000X
MS21852207P00000X
MN63144207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07400813Medicaid
MSP01228848OtherRR MEDICARE PTAN
MS07400813Medicaid
MS302I938581Medicare PIN