Provider Demographics
NPI:1972571669
Name:NUSSBAUM, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:NUSSBAUM
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 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:
Practice Address - Street 1:3 RIVERSIDE CIR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4955
Practice Address - Country:US
Practice Address - Phone:540-224-5170
Practice Address - Fax:540-983-8213
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101262004208600000X
OH35-051873208600000X
FLME1019042086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA880631957AMedicaid
FL0000539-00Medicaid
OHNU0583091Medicare ID - Type Unspecified
OHA16438Medicare UPIN
OH0583095Medicare PIN
GA880631957AMedicaid
FLAT853ZMedicare PIN