Provider Demographics
NPI:1174878086
Name:MACIKOWSKI, MICHAEL JOSEPH (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:MACIKOWSKI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 E RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-1240
Mailing Address - Country:US
Mailing Address - Phone:585-922-0400
Mailing Address - Fax:585-922-0455
Practice Address - Street 1:370 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-1240
Practice Address - Country:US
Practice Address - Phone:585-922-0400
Practice Address - Fax:585-922-0455
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03406397/WNYMedicaid
NY01131126/RGHMedicaid
NY03570596Medicaid
NYJ100058113/WNYMedicare PIN
NY70005A/RGHMedicare PIN
NYJ400076345Medicare PIN
NY03406397/WNYMedicaid