Provider Demographics
NPI:1699723247
Name:ARCHDEACON, MICHAEL T (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:ARCHDEACON
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:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-585-5506
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:222 PIEDMONT AVE
Practice Address - Street 2:SUITE 2200
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-4231
Practice Address - Country:US
Practice Address - Phone:513-475-8690
Practice Address - Fax:513-475-7243
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069283A207XX0801X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200321580Medicaid
OH200041359OtherRAILROAD MEDICARE
OH2246920Medicaid
KY64035629Medicaid
OHAR4044261Medicare PIN
OH200041359OtherRAILROAD MEDICARE