Provider Demographics
NPI:1023410222
Name:PHYTHIAN, MICHAEL J (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:PHYTHIAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9919 SHINING WILLOW DR APT 102
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-3152
Mailing Address - Country:US
Mailing Address - Phone:734-306-9822
Mailing Address - Fax:
Practice Address - Street 1:1025 NEW MOODY LN
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9154
Practice Address - Country:US
Practice Address - Phone:502-222-3886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28217658A163W00000X, 367500000X
KY105991367500000X
KY3015571367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100736760Medicaid
IN300019427Medicaid
IN300019427Medicaid