1487686051 NPI number — DR. PHILLIP JOHN MICHALOS O.D.

Table of content: DR. PHILLIP JOHN MICHALOS O.D. (NPI 1487686051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487686051 NPI number — DR. PHILLIP JOHN MICHALOS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICHALOS
Provider First Name:
PHILLIP
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487686051
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16400 HILLIARD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44107-5610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-228-1800
Provider Business Mailing Address Fax Number:
216-228-1162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10680 LORAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44111-5411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-671-2998
Provider Business Practice Location Address Fax Number:
216-671-6985
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3426 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0324232 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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