Basic Information
| Provider Information | |||||||||
| NPI: | 1154478055 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHELIN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2414 | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959452414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302731914 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 155 GLASSON WAY | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959455723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302746000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | C36138 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00361380 | 05 | CA | MEDICAID |