Provider Demographics
NPI:1982689758
Name:ABOURJEILY, MIKHAEL T (DO)
Entity Type:Individual
Prefix:
First Name:MIKHAEL
Middle Name:T
Last Name:ABOURJEILY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 DARROW RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-5021
Mailing Address - Country:US
Mailing Address - Phone:330-656-5911
Mailing Address - Fax:330-656-5901
Practice Address - Street 1:8655 MARKET STREET
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060
Practice Address - Country:US
Practice Address - Phone:440-255-6400
Practice Address - Fax:440-255-3637
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005104A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000383091OtherANTHEM
OH001822820-0001OtherPENNSYLVANIA MEDICAID
OH0848631Medicaid
OH0848631Medicaid
OH080183512Medicare PIN
OHAB0874313Medicare PIN