Provider Demographics
NPI:1629092655
Name:PATRICK, MICHAEL R (AA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:PATRICK
Suffix:
Gender:M
Credentials:AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67-000118367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH415019OtherWELLCARE MEDICAID
OH000000232299OtherUNISON
OH0583328OtherBCMH
OHP00802872OtherMEDICARE RAILROAD
OH2739219Medicaid
OH7819952OtherAETNA
OH000000515971OtherANTHEM
OHPA7338431Medicare PIN
OH0583328OtherBCMH