Marco Distefano, AT, ATC

Primary specialty

Athletic TrainerTaxonomy code 2255A2300X

License

2601002258 Issued in MI

Practice address

7400 Bay Rd
University Center, MI 48710-0001

Phone

(989) 964-7233

NPI assigned

Jun 18, 2021

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1623974400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1623974400000",
    "number": "1790354405",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "48541 HENNINGS DR",
            "city": "MACOMB",
            "state": "MI",
            "postal_code": "480445615",
            "telephone_number": "586-549-3663"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7400 BAY RD",
            "city": "UNIVERSITY CENTER",
            "state": "MI",
            "postal_code": "487100001",
            "telephone_number": "989-964-7233"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DISTEFANO",
        "first_name": "MARCO",
        "credential": "AT, ATC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-06-18",
        "last_updated": "2021-06-18",
        "certification_date": "2021-06-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "MI",
            "license": "2601002258",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• David Charles Berry, PHD, ATC
• Gabrielle Ann Cameron
• Madeline Moriah David, MSN, APRN, FNP-BC
• Andrea Dell, MSOTRL
• Jacqueline Marie Detrick, M.ED., ATC
• Megan Frizzell
• Ryan Timothy Gibeau, ATC
• Jeremy Eugene Glaser, MS, ATC
• Jacob John Heckman, ATC
• Sarah Hinkle

• Athletic Trainer in University Center, MI
• Providers in University Center, MI by specialty
• Athletic Trainer in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 18, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.