Basic Information
Provider Information | |||||||||
NPI: | 1437499076 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPIVAK | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN, CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5800 TRAILSIDE CT | ||||||||
Address2: |   | ||||||||
City: | MASON | ||||||||
State: | OH | ||||||||
PostalCode: | 450407047 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138913636 | ||||||||
FaxNumber: | 5136041005 | ||||||||
Practice Location | |||||||||
Address1: | 969 READING RD STE N | ||||||||
Address2: |   | ||||||||
City: | MASON | ||||||||
State: | OH | ||||||||
PostalCode: | 450402654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5136041004 | ||||||||
FaxNumber: | 5134370571 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2013 | ||||||||
LastUpdateDate: | 04/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP-14261 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 7100510650 | 05 | KY |   | MEDICAID | 0079958 | 05 | OH |   | MEDICAID |