Healthcare Provider Details

I. General information

NPI: 1619559952
Provider Name (Legal Business Name): MICHAEL ROBERT DEITERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 E BROAD ST
COLUMBUS OH
43213-1502
US

IV. Provider business mailing address

6001 E BROAD ST
COLUMBUS OH
43213-1502
US

V. Phone/Fax

Practice location:
  • Phone: 614-234-6000
  • Fax:
Mailing address:
  • Phone: 614-234-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.0029538
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.421447
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: