Provider Demographics
NPI:1467752220
Name:SERVIS, MICAH LEE (SA-C)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:LEE
Last Name:SERVIS
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 19679
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9679
Mailing Address - Country:US
Mailing Address - Phone:217-545-5878
Mailing Address - Fax:217-545-2586
Practice Address - Street 1:747 N RUTLEDGE ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6700
Practice Address - Country:US
Practice Address - Phone:217-545-5878
Practice Address - Fax:217-545-2586
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL238-000264363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical