1265437867 NPI number — MICHAEL A NOVAK MD

Table of content: MICHAEL A NOVAK MD (NPI 1265437867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265437867 NPI number — MICHAEL A NOVAK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOVAK
Provider First Name:
MICHAEL
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1265437867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24075 COMMERCE PARK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEACHWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44122-5846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-831-5700
Provider Business Mailing Address Fax Number:
216-839-4905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3401 ENTERPRISE PKWY
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
BEACHWOOD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44122-7344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-831-5700
Provider Business Practice Location Address Fax Number:
216-839-4905
Provider Enumeration Date:
06/20/2005

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: 207W00000X , with the licence number:  048833 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207WX0107X , with the licence number: 35-048833 , 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: 0826931 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000027302 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 180030562 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0004057921 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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