Provider Demographics
NPI:1184666349
Name:YERARDI, MICHAEL R (PAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:YERARDI
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 CONGRESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4133
Mailing Address - Country:US
Mailing Address - Phone:800-726-3627
Mailing Address - Fax:
Practice Address - Street 1:332 CONGRESS PARK DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4133
Practice Address - Country:US
Practice Address - Phone:800-726-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000751363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S67161Medicare UPIN