Provider Demographics
NPI:1912917642
Name:LORADITCH, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LORADITCH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WALDORF DR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-8741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:HOSPITAL BOX 64
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-633-2097
Practice Address - Fax:478-633-7836
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97BBFCTMedicare ID - Type Unspecified
S90152Medicare UPIN