Provider Demographics
NPI:1376521708
Name:MICHAEL, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E RAVINE RD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3814
Mailing Address - Country:US
Mailing Address - Phone:423-245-9600
Mailing Address - Fax:423-245-9634
Practice Address - Street 1:210 WESTWOOD PL STE 110
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7554
Practice Address - Country:US
Practice Address - Phone:615-206-2462
Practice Address - Fax:833-983-2043
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045149207Q00000X
TNMD26094207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508847Medicaid