Basic Information
| Provider Information | |||||||||
| NPI: | 1588618029 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAU | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | JOE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 BLUE RIDGE RD STE 417 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276077516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197879097 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4420 LAKE BOONE TRL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276077505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197843100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 9900612 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 891227C | 05 | NC | MEDICAID | BM5664227 | 01 | DEA | OTHER |