Michael Matthew Novellino, LAT, ATC, CEAS III

Primary specialty

Athletic TrainerTaxonomy code 2255A2300X

License

AT005847 Issued in OH

Practice address

800 Fuyao Ave
Moraine, OH 45439-7500

Phone

(937) 493-5777

NPI assigned

May 23, 2016

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1463961600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1588723200000",
    "number": "1720435456",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2550 STEEPLECHASE DR",
            "city": "MIAMISBURG",
            "state": "OH",
            "postal_code": "453425501",
            "telephone_number": "848-459-7683"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "800 FUYAO AVE",
            "city": "MORAINE",
            "state": "OH",
            "postal_code": "454397500",
            "telephone_number": "937-493-5777"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "NOVELLINO",
        "first_name": "MICHAEL",
        "middle_name": "MATTHEW",
        "name_prefix": "Mr.",
        "credential": "LAT, ATC, CEAS III",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-05-23",
        "last_updated": "2020-05-06",
        "certification_date": "2020-05-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "OH",
            "license": "AT005847",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Athletic Trainer in Moraine, OH
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• Athletic Trainer in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.