Provider Demographics
NPI:1144356973
Name:MAHONEY, MICHAEL JAMES
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 PARK AVE S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3736
Mailing Address - Country:US
Mailing Address - Phone:320-252-0452
Mailing Address - Fax:
Practice Address - Street 1:215 PARK AVE S
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3736
Practice Address - Country:US
Practice Address - Phone:320-252-0452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2067237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN45-80212Medicaid
MN45-00200Medicaid
MN110204Medicaid
MN55030CLOtherBLUE CROSS& BLUE SHIELD
MN82-81124Medicaid