MEDICARE: MR. MICHAEL DE'AUNTE BLUE SR.

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	374U00000X	Home Health Aide	812306467	OH

General Provider Information

NPI Number	:	1497109029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL DE'AUNTE BLUE SR.

Provider Business Mailing Address
First Line	:	3781 MONTICELLO BLVD
Second Line	:
City	:	CLEVELAND HTS
State	:	OH
Zip	:	44121-1846
Country	:	US
Telephone Number	:	216-777-0226
Fax Number	:

Provider Business Practice Location Address
First Line	:	3781 MONTICELLO BLVD
Second Line	:
City	:	CLEVELAND HTS
State	:	OH
Zip	:	44121-1846
Country	:	US
Telephone Number	:	216-777-0226
Fax Number	:

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

Provider Enumeration Date	:	04/20/2016
Last Update Date	:	04/20/2016

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