Provider Demographics
NPI:1255329090
Name:FISHER, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:DO
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 469
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-0009
Mailing Address - Country:US
Mailing Address - Phone:270-824-9222
Mailing Address - Fax:270-824-8088
Practice Address - Street 1:44 MCCOY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-2963
Practice Address - Country:US
Practice Address - Phone:270-824-9222
Practice Address - Fax:270-824-8088
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02199207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200377020Medicaid
KY64021991Medicaid
KY0693701Medicare ID - Type Unspecified
F55193Medicare UPIN