Provider Demographics
NPI:1497109029
Name:BLUE, MICHAEL DE'AUNTE SR
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DE'AUNTE
Last Name:BLUE
Suffix:SR
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 1:3781 MONTICELLO BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44121-1846
Mailing Address - Country:US
Mailing Address - Phone:216-777-0226
Mailing Address - Fax:
Practice Address - Street 1:3781 MONTICELLO BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44121-1846
Practice Address - Country:US
Practice Address - Phone:216-777-0226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH812306467374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide