Healthcare Provider Details

I. General information

NPI: 1629005814
Provider Name (Legal Business Name): MICHAEL D PRIVITERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3113 BELLEVUE AVE FL 3
CINCINNATI OH
45219-3158
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 513-652-6500
  • Fax: 513-475-8033
Mailing address:
  • Phone: 513-585-5504
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number35054494
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number35054494
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: