Provider Demographics
NPI:1104092337
Name:MICHAEL J CHARBONEAU JR DO PLLC
Entity type:Organization
Organization Name:MICHAEL J CHARBONEAU JR DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:CHARBONEAU
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:734-241-4245
Mailing Address - Street 1:730 N MACOMB ST
Mailing Address - Street 2:SUITE 329
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2900
Mailing Address - Country:US
Mailing Address - Phone:734-241-4245
Mailing Address - Fax:734-242-8903
Practice Address - Street 1:730 N MACOMB ST
Practice Address - Street 2:SUITE 329
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-2900
Practice Address - Country:US
Practice Address - Phone:734-241-4245
Practice Address - Fax:734-242-8903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010247208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0255810524OtherBLUE CROSS
MI4218443Medicaid
MI0N12480Medicare PIN
MIG22695Medicare UPIN