Provider Demographics
NPI:1184410763
Name:SUPONCIC, MICHAEL BLAKE
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BLAKE
Last Name:SUPONCIC
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SOUTH POINTE HOSPITAL
Mailing Address - Street 2:20000 HARVARD RD.
Mailing Address - City:WARRENSVILLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-491-6000
Mailing Address - Fax:
Practice Address - Street 1:SOUTH POINTE HOSPITAL
Practice Address - Street 2:20000 HARVARD RD.
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-491-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-18
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program