Provider Demographics
NPI:1265280333
Name:MUCKERHEIDE, ETHAN HUGH
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:HUGH
Last Name:MUCKERHEIDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7425 CHESHIRE RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4202
Mailing Address - Country:US
Mailing Address - Phone:937-657-8899
Mailing Address - Fax:
Practice Address - Street 1:7425 CHESHIRE RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4202
Practice Address - Country:US
Practice Address - Phone:937-657-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator