MEDICARE: RAYMOND W MICK CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN180620	OH
2	363L00000X	Nurse Practitioner	NP07584	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	363844	OTHER	OH	RHC MEDICARE FAC #
3	363843	OTHER	OH	RHC MEDICARE 2ND FAC NUM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	311674981002	OTHER	OH	TRI-CARE 2ND FACILITY #
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	311674981005	OTHER	OH	TRI-CARE
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	000000344735	OTHER	OH	ANTHEM

General Provider Information

NPI Number	:	1437141561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYMOND W MICK CNP

Provider Business Mailing Address
First Line	:	PO BOX 637736
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-7736
Country	:	US
Telephone Number	:	513-891-1006
Fax Number	:	513-793-1032

Provider Business Practice Location Address
First Line	:	1092 JEFFERSON ST
Second Line	:
City	:	GREENFIELD
State	:	OH
Zip	:	45123-8319
Country	:	US
Telephone Number	:	937-981-1121
Fax Number	:	937-981-5660

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	10/02/2012

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