Provider Demographics
NPI:1194710285
Name:SHEVACH, MICHAEL N (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:N
Last Name:SHEVACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:ATTN: MEDICAL STAFF OFFICE
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3525 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-1965
Practice Address - Country:US
Practice Address - Phone:863-603-6565
Practice Address - Fax:863-904-1961
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00513432085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL144026-01OtherCITRUS HLTHCR. PROVIDER #
FL4262347OtherAETNA PROVIDER NUMBER
FL592485899OtherMETCARE VENDOR ID #
FL5899OtherAVMED PIN NUMBER
FLME51343OtherMETCARE PROVIDER ID #
FL298196OtherWELLCARE PROVIDER NUMBER
FL269994OtherAVMED PROVIDER NUMBER
FLE57137Medicare UPIN
FL49532SMedicare PIN
FL207227OtherAMERIGROUP GROUP NUMBER
FL6700133-009OtherCIGNA PROVIDER NUMBER
FL102843OtherOP. ENG. LOC. 825 PROV. #
FL265262500Medicaid