Healthcare Provider Details

I. General information

NPI: 1104313600
Provider Name (Legal Business Name): MICHAEL A TIBURZIO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 W SCHROCK RD
WESTERVILLE OH
43081-2890
US

IV. Provider business mailing address

DEPT. 781625 PO BOX 78000
DETROIT MI
48278-1625
US

V. Phone/Fax

Practice location:
  • Phone: 614-355-7500
  • Fax: 614-355-7533
Mailing address:
  • Phone: 614-355-8004
  • Fax: 614-355-2220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: