Basic Information
| Provider Information | |||||||||
| NPI: | 1295706299 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHEATLEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 999 EXECUTIVE PARK BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243250 | ||||||||
| FaxNumber: | 4232243258 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WISE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242936904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763287071 | ||||||||
| FaxNumber: | 2763286082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 07/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101051183 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64666795 | 05 | KY | MEDICAID | 080081762 | 01 | VA | RAILROAD MEDICARE | OTHER | 006086543 | 05 | VA | MEDICAID |