Provider Demographics
NPI:1437499076
Name:SPIVAK, MICHAEL (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SPIVAK
Suffix:
Gender:M
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 TRAILSIDE CT
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-7047
Mailing Address - Country:US
Mailing Address - Phone:513-891-3636
Mailing Address - Fax:513-604-1005
Practice Address - Street 1:969 READING RD STE N
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-2654
Practice Address - Country:US
Practice Address - Phone:513-604-1004
Practice Address - Fax:513-437-0571
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-14261363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100510650Medicaid
OH0079958Medicaid