Basic Information
| Provider Information | |||||||||
| NPI: | 1134445364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TABONE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 63308 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282633308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662643435 | ||||||||
| FaxNumber: | 8649871611 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 HERLONG AVE S | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297321158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033291234 | ||||||||
| FaxNumber: | 8649871611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2010 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 83086 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 279668-1 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 02637 | TN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X | 58.003192 | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 830863 | 05 | SC | MEDICAID |