Basic Information
| Provider Information | |||||||||
| NPI: | 1700863503 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOVAKOSKY | ||||||||
| FirstName: | MARCELA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1848 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494431848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317274444 | ||||||||
| FaxNumber: | 2317284789 | ||||||||
| Practice Location | |||||||||
| Address1: | 1675 LEAHY ST | ||||||||
| Address2: | SUITE 201A | ||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494425500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316727800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 06/15/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301062838 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4287718 | 05 | MI | MEDICAID |