Healthcare Provider Details

I. General information

NPI: 1639266679
Provider Name (Legal Business Name): THOMAS MARCUS MICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE
CLEVELAND OH
44195-0002
US

IV. Provider business mailing address

9500 EUCLID AVE
CLEVELAND OH
44195-0002
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-5807
  • Fax: 216-587-8646
Mailing address:
  • Phone: 216-444-5807
  • Fax: 216-587-8646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number60 238722
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number60 238722
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number60 238722
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number35.137477
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: