Basic Information
Provider Information | |||||||||
NPI: | 1083607451 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WAITE | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 20452 | ||||||||
Address2: | COA-CRED | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432200452 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6144422406 | ||||||||
FaxNumber: | 6144422410 | ||||||||
Practice Location | |||||||||
Address1: | 3535 OLENTANGY RIVER RD | ||||||||
Address2: | RMH 4 TOWER ICU | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432143908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6145664691 | ||||||||
FaxNumber: | 6145666854 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2005 | ||||||||
LastUpdateDate: | 01/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 35067189 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
ID | Type | State | Issuer | Description | 0987875 | 05 | OH |   | MEDICAID | WA4046881 | 01 | OH | RR MEDICARE | OTHER |