1578003802 NPI number — MICHELLE M BAILEY PA-C

Table of content: MICHELLE M BAILEY PA-C (NPI 1578003802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578003802 NPI number — MICHELLE M BAILEY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAILEY
Provider First Name:
MICHELLE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FORD
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578003802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13170 RAVENNA RD #200
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CHARDON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44024-4426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-542-6363
Provider Business Mailing Address Fax Number:
440-279-1582

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13170 RAVENNA ROAD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CHARDON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-542-6363
Provider Business Practice Location Address Fax Number:
440-279-1582
Provider Enumeration Date:
03/06/2017

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: 363AS0400X , with the licence number:  50.004977RX , 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: H507850 . This is a "MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: H507851 . This is a "MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0211306 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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