Basic Information
| Provider Information | |||||||||
| NPI: | 1376521708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAEL | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 E RAVINE RD | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232459600 | ||||||||
| FaxNumber: | 4232459634 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 WESTWOOD PL STE 110 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152062462 | ||||||||
| FaxNumber: | 8339832043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101045149 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD26094 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1508847 | 05 | TN | MEDICAID |