Provider Demographics
NPI:1063581395
Name:CARLISLE, MICHAEL CLIFFORD (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CLIFFORD
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:THIRD FLOOR BILLING SERVICES
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:216-844-2400
Mailing Address - Fax:440-285-6247
Practice Address - Street 1:13207 RAVENNA RD
Practice Address - Street 2:SENIOR ASSESSMENT PROGRAM
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-7032
Practice Address - Country:US
Practice Address - Phone:216-844-2400
Practice Address - Fax:440-285-6247
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340087722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2854817Medicaid