Basic Information
Provider Information | |||||||||
NPI: | 1821023003 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHANEY | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2935 THOUSAND OAKS DR STE 294 | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782473563 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2104941100 | ||||||||
FaxNumber: | 2104941117 | ||||||||
Practice Location | |||||||||
Address1: | 211 RANCH ROAD 620 S STE 130 | ||||||||
Address2: |   | ||||||||
City: | LAKEWAY | ||||||||
State: | TX | ||||||||
PostalCode: | 787343966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5126144111 | ||||||||
FaxNumber: | 5126144183 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 08/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | E4248 | TX | N |   | Allopathic & Osteopathic Physicians | Plastic Surgery |   | 2083P0011X | E4248 | TX | N |   | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine | 2086S0122X | E4248 | TX | Y |   | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
ID | Type | State | Issuer | Description | AC7365883 | 01 |   | DEA US DEPT OF JUSTICE | OTHER | C0029638 | 01 | TX | TX DPS CERT | OTHER | E4248 | 01 | TX | MED LICENSE | OTHER |