Provider Demographics
NPI:1154390292
Name:POLE, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:POLE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5500
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-5500
Mailing Address - Country:US
Mailing Address - Phone:903-663-4800
Mailing Address - Fax:419-223-2726
Practice Address - Street 1:725 S SHOOP AVE
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1702
Practice Address - Country:US
Practice Address - Phone:419-335-2015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0682702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00358054OtherRAILROAD MEDICARE
OH000000491789OtherANTHEM BCBS
OH2020128Medicaid
MI4947873Medicaid
G54311Medicare UPIN
OH2020128Medicaid