Basic Information
| Provider Information | |||||||||
| NPI: | 1437141561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICK | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 637736 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452637736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138911006 | ||||||||
| FaxNumber: | 5137931032 | ||||||||
| Practice Location | |||||||||
| Address1: | 1092 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451238319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379811121 | ||||||||
| FaxNumber: | 9379815660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 10/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN180620 | OH | N | Nursing Service Providers | Registered Nurse | 363L00000X | NP07584 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2499005 | 05 | OH | MEDICAID | 363844 | 01 | OH | RHC MEDICARE FAC # | OTHER | 363843 | 01 | OH | RHC MEDICARE 2ND FAC NUM | OTHER | 311674981002 | 01 | OH | TRI-CARE 2ND FACILITY # | OTHER | 2355062 | 01 | OH | RHC MEDICAID 2ND FAC # | OTHER | 311674981005 | 01 | OH | TRI-CARE | OTHER | 2355053 | 01 | OH | RHC MEDICAID FACILITY # | OTHER | 000000344735 | 01 | OH | ANTHEM | OTHER |