Provider Demographics
NPI:1154363240
Name:TAYLOR, MICHAEL GEORGE (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GEORGE
Last Name:TAYLOR
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 1:24535 JEFFERSON AVE
Mailing Address - Street 2:STE C
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2898
Mailing Address - Country:US
Mailing Address - Phone:586-443-5400
Mailing Address - Fax:586-443-5403
Practice Address - Street 1:22646 NINE MILE ROAD
Practice Address - Street 2:STE C
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1951
Practice Address - Country:US
Practice Address - Phone:586-443-5400
Practice Address - Fax:586-443-5403
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI405365208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4134989Medicaid
OM86170Medicare ID - Type Unspecified
F42118Medicare UPIN