Provider Demographics
NPI:1114986015
Name:STANICH, MICHAEL P (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:STANICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7067 TIFFANY BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-1981
Mailing Address - Country:US
Mailing Address - Phone:330-726-9077
Mailing Address - Fax:330-726-8715
Practice Address - Street 1:7067 TIFFANY BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514-1981
Practice Address - Country:US
Practice Address - Phone:330-726-9077
Practice Address - Fax:330-726-8715
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003460207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0516098Medicaid
OH0534651Medicare PIN
E00685Medicare UPIN