Healthcare Provider Details

I. General information

NPI: 1437141561
Provider Name (Legal Business Name): RAYMOND W MICK CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1092 JEFFERSON ST
GREENFIELD OH
45123-8319
US

IV. Provider business mailing address

PO BOX 637736
CINCINNATI OH
45263-7736
US

V. Phone/Fax

Practice location:
  • Phone: 937-981-1121
  • Fax: 937-981-5660
Mailing address:
  • Phone: 513-891-1006
  • Fax: 513-793-1032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN180620
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP07584
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: