Provider Demographics
NPI:1487863197
Name:MACEJKO, MICHAEL J JR (ATC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:MACEJKO
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
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Mailing Address - Street 1:1525 TERRACE BLVD
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-7527
Mailing Address - Country:US
Mailing Address - Phone:570-455-0921
Mailing Address - Fax:
Practice Address - Street 1:1601 W 23RD ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-1646
Practice Address - Country:US
Practice Address - Phone:570-459-3221
Practice Address - Fax:570-459-3139
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART000213A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer