Provider Demographics
NPI:1992146740
Name:WELLER, MICHAEL JEROME (NP-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEROME
Last Name:WELLER
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9775 COLERAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45251-1442
Mailing Address - Country:US
Mailing Address - Phone:513-853-9700
Mailing Address - Fax:513-852-8971
Practice Address - Street 1:9775 COLERAIN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45251-1442
Practice Address - Country:US
Practice Address - Phone:513-853-9700
Practice Address - Fax:513-852-8971
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009646363L00000X
OHCOA.14647-NP363LF0000X
OHAPRN.CNP.14647363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0215521Medicaid