Provider Demographics
NPI:1467904391
Name:NORDGREN, MICHAEL JAMES
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:NORDGREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4438 MOBILE DRIVE APT. 302
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220
Mailing Address - Country:US
Mailing Address - Phone:605-201-9226
Mailing Address - Fax:
Practice Address - Street 1:535 IRVING SCHOTTENSTEIN DR.
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220
Practice Address - Country:US
Practice Address - Phone:614-201-9226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0050972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer