Provider Demographics
NPI:1437141561
Name:MICK, RAYMOND W (CNP)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:W
Last Name:MICK
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 637736
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-7736
Mailing Address - Country:US
Mailing Address - Phone:513-891-1006
Mailing Address - Fax:513-793-1032
Practice Address - Street 1:1092 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:OH
Practice Address - Zip Code:45123-8319
Practice Address - Country:US
Practice Address - Phone:937-981-1121
Practice Address - Fax:937-981-5660
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN180620163W00000X
OHNP07584363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2499005Medicaid
OH363844OtherRHC MEDICARE FAC #
OH363843OtherRHC MEDICARE 2ND FAC NUM
OH311674981002OtherTRI-CARE 2ND FACILITY #
OH2355062OtherRHC MEDICAID 2ND FAC #
OH311674981005OtherTRI-CARE
OH2355053OtherRHC MEDICAID FACILITY #
OH000000344735OtherANTHEM
OH2355062OtherRHC MEDICAID 2ND FAC #
Q18478Medicare UPIN