Provider Demographics
NPI:1922047778
Name:NILL, MICHAEL R (MD FACS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:NILL
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 BENEDICT AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-2374
Mailing Address - Country:US
Mailing Address - Phone:419-668-8101
Mailing Address - Fax:419-660-2686
Practice Address - Street 1:272 BENEDICT AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-2374
Practice Address - Country:US
Practice Address - Phone:419-668-8101
Practice Address - Fax:419-660-2686
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.065471208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3004040000Medicaid
OH000000490582OtherANTHEM
OH2190294Medicaid
OHP00343382OtherRRMCR
OH000000696939OtherANTHEM
OH7418921Medicare PIN
OH000000490582OtherANTHEM
OH000000696939OtherANTHEM