Basic Information
| Provider Information | |||||||||
| NPI: | 1578003802 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FORD | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13170 RAVENNA RD #200 | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440244426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8445426363 | ||||||||
| FaxNumber: | 4402791582 | ||||||||
| Practice Location | |||||||||
| Address1: | 13170 RAVENNA ROAD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8445426363 | ||||||||
| FaxNumber: | 4402791582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2017 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 50.004977RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | H507850 | 01 | OH | MEDICARE | OTHER | H507851 | 01 | OH | MEDICARE | OTHER | 0211306 | 05 | OH | MEDICAID |