Individual
IRA MICKELSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1777 AXTELL, SUITE 102, TROY, MI 48084
(248) 822-6200
Mailing address
1777 AXTELL, SUITE 102, TROY, MI 48084
(248) 822-6200
Taxonomy
Speciality
Code
Description
License number
State
207QA0401X
Addiction Medicine (Family Medicine) Physician
5304001863
MI
207V00000X
Obstetrics & Gynecology Physician
Primary
IM043839
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
160F318220
BCBS OF MICHIGAN
MI
Enumeration date
10/03/2006
Last updated
11/13/2018
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