Provider Demographics
NPI:1689435810
Name:NELSON, MICHAEL PHILLIP
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PHILLIP
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MCINTYRE CENTER
Mailing Address - Street 2:6900 RIDGE ROAD
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5650
Mailing Address - Country:US
Mailing Address - Phone:440-887-1100
Mailing Address - Fax:440-887-1103
Practice Address - Street 1:14707 S CHESHIRE ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:OH
Practice Address - Zip Code:44021-9601
Practice Address - Country:US
Practice Address - Phone:440-887-1100
Practice Address - Fax:110-887-1103
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0053456Medicaid