Provider Demographics
NPI:1477392710
Name:GAMBLE, MICHAEL EARL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EARL
Last Name:GAMBLE
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 1:3212 W 97TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-4744
Mailing Address - Country:US
Mailing Address - Phone:216-356-9186
Mailing Address - Fax:
Practice Address - Street 1:3212 W 97TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-4744
Practice Address - Country:US
Practice Address - Phone:216-356-9186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH343900000X342000000X
OH342000000X, 305R00000X
342000000X, 347E00000X, 3747A0650X
OH873328741342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No342000000XTransportation ServicesTransportation Network Company
No347E00000XTransportation ServicesTransportation Broker
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider