Basic Information
| Provider Information | |||||||||
| NPI: | 1487608543 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYRACLE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4437 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937444437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594858330 | ||||||||
| FaxNumber: | 5594856994 | ||||||||
| Practice Location | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936388761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594858330 | ||||||||
| FaxNumber: | 5594856694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 09/12/2009 | ||||||||
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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 | 2085P0229X | G38925 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G389250 | 05 | CA | MEDICAID |