Basic Information
| Provider Information | |||||||||
| NPI: | 1063495521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAELSON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | EVAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704221372 | ||||||||
| FaxNumber: | 7704239651 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704221372 | ||||||||
| FaxNumber: | 7704239651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 037623 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | 37623 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 037623 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 00645147C | 05 | GA | MEDICAID | 2999766 | 01 | GHI | OTHER | 202I294296 | 01 | GA | MEDICARE PTAN | OTHER | 290012142 | 01 | GA | RAILROAD MEDICARE | OTHER | 5341107 | 01 | AETNA | OTHER | 58-1831482 | 01 | GA | FEDERAL TAX IDENTIFICATION NUMBER | OTHER | 767305 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | 0932200001 | 01 | GA | WORKERS COMPENSATION | OTHER | 5932 | 01 | GA | KAISER | OTHER | 6054810006 | 01 | CIGNA | OTHER | 4820111 | 01 | UNITED HEALTHCARE | OTHER |