Provider Demographics
NPI:1053065276
Name:PARK, MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 681478
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-1478
Mailing Address - Country:US
Mailing Address - Phone:615-673-1420
Mailing Address - Fax:615-673-1421
Practice Address - Street 1:7640 HWY 70 S STE 210
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37221-1758
Practice Address - Country:US
Practice Address - Phone:615-673-1420
Practice Address - Fax:615-673-1421
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13989225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0446631Medicaid