Basic Information
| Provider Information | |||||||||
| NPI: | 1437203650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RACINE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1031 E SAGINAW STREET | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174871288 | ||||||||
| FaxNumber: | 5174871129 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W GREENLAWN | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174871288 | ||||||||
| FaxNumber: | 5174871129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 4301079892 | MI | N | Other Service Providers | Specialist | 207P00000X | 4301079892 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 382168683 | 01 | MI | TAX ID | OTHER | 4743659 | 05 | MI | MEDICAID |