Provider Demographics
NPI:1386263614
Name:MICHAEL, GENE THOMAS
Entity type:Individual
Prefix:
First Name:GENE
Middle Name:THOMAS
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 N COLUMBUS ST STE 260
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-8296
Mailing Address - Country:US
Mailing Address - Phone:740-687-8397
Mailing Address - Fax:740-654-4103
Practice Address - Street 1:2401 N COLUMBUS ST STE 260
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-8296
Practice Address - Country:US
Practice Address - Phone:740-687-8397
Practice Address - Fax:740-654-4103
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-16
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.031751207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty