Provider Demographics
NPI:1114192895
Name:JOHN D MICHELMAN, MD, PSC
Entity Type:Organization
Organization Name:JOHN D MICHELMAN, MD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DERR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-744-9600
Mailing Address - Street 1:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-0834
Practice Address - Street 1:861 CORPORATE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-5432
Practice Address - Country:US
Practice Address - Phone:859-224-2022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY375232084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9708Medicare PIN