Basic Information
| Provider Information | |||||||||
| NPI: | 1972554822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OSTAPCHUK | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234396464 | ||||||||
| FaxNumber: | 4234397118 | ||||||||
| Practice Location | |||||||||
| Address1: | 917 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234396464 | ||||||||
| FaxNumber: | 4234397118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 08/24/2018 | ||||||||
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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 | 27248 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | 27248 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | MD56839 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64272487 | 05 | KY | MEDICAID | 200162470 | 05 | IN | MEDICAID |