Provider Demographics
NPI:1053382275
Name:FITZPATRICK, MICAHEL L (MD)
Entity type:Individual
Prefix:
First Name:MICAHEL
Middle Name:L
Last Name:FITZPATRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7507 ANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-9550
Mailing Address - Country:US
Mailing Address - Phone:419-866-2178
Mailing Address - Fax:
Practice Address - Street 1:921 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:KENTON
Practice Address - State:OH
Practice Address - Zip Code:43326-2020
Practice Address - Country:US
Practice Address - Phone:419-675-8328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052675F207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0627521Medicaid
OH0599535Medicare PIN
OHA16937Medicare UPIN
OH0627521Medicaid