Provider Demographics
NPI:1801966122
Name:MAUGER, THEODORE FITCH (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:FITCH
Last Name:MAUGER
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 1:1325 THORNAPPLE RIVER DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-9736
Mailing Address - Country:US
Mailing Address - Phone:616-676-0208
Mailing Address - Fax:
Practice Address - Street 1:1325 THORNAPPLE RIVER DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-9736
Practice Address - Country:US
Practice Address - Phone:616-676-0208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010392232084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D91312Medicare UPIN
0-410001Medicare ID - Type Unspecified