Provider Demographics
NPI:1124026331
Name:SERVOSS, MICHAEL M (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:SERVOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2914 S REPUBLIC BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-1912
Mailing Address - Country:US
Mailing Address - Phone:419-531-8808
Mailing Address - Fax:419-531-9342
Practice Address - Street 1:2142 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3895
Practice Address - Country:US
Practice Address - Phone:419-471-4491
Practice Address - Fax:419-479-6905
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059596207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH050064685OtherRAILROAD MEDICARE
MI104071539OtherMICHIGAN MEDICAID
OH0819627OtherBCMH
OH0819627Medicaid
OH0825765Medicare ID - Type UnspecifiedOHIO MEDICARE
OH0819627Medicaid