Healthcare Provider Details

I. General information

NPI: 1548607278
Provider Name (Legal Business Name): MICHAEL JASON BISHOP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 W MARKET ST STE 100
LIMA OH
45805-2796
US

IV. Provider business mailing address

PO BOX 636930
CINCINNATI OH
45263-6930
US

V. Phone/Fax

Practice location:
  • Phone: 419-996-5063
  • Fax: 419-996-5502
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number4301104770
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number35.139922
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: