Provider Demographics
NPI:1912064296
Name:STAEBLER, MICHAEL PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
Last Name:STAEBLER
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:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02901-1119
Mailing Address - Country:US
Mailing Address - Phone:401-842-0555
Mailing Address - Fax:401-847-5450
Practice Address - Street 1:345 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-5236
Practice Address - Country:US
Practice Address - Phone:401-842-0555
Practice Address - Fax:401-847-5450
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD09775207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7006584Medicaid
RI201596530OtherTRICARE
RI201596530OtherTRICARE
007056979Medicare ID - Type Unspecified
RI201596530OtherTRICARE
RI403092OtherBLUE CHIP