Provider Demographics
NPI:1811160476
Name:MICHAEL MAKEDONSKY PHD
Entity type:Organization
Organization Name:MICHAEL MAKEDONSKY PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAKEDONSKY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:616-957-0731
Mailing Address - Street 1:PO BOX 120125
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49528-0103
Mailing Address - Country:US
Mailing Address - Phone:616-235-2090
Mailing Address - Fax:616-235-2099
Practice Address - Street 1:3501 LAKE EASTBROOK BLVD SE STE 222
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5940
Practice Address - Country:US
Practice Address - Phone:616-957-0731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty