Provider Demographics
NPI:1467452425
Name:MICHAELIS, NANCY G (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:G
Last Name:MICHAELIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 EAST THIRD STREET
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2147
Mailing Address - Country:US
Mailing Address - Phone:423-778-3110
Mailing Address - Fax:423-778-3146
Practice Address - Street 1:975 EAST THIRD STREET
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403
Practice Address - Country:US
Practice Address - Phone:423-266-1490
Practice Address - Fax:423-778-2108
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047020207R00000X
TNMD0000051271207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010230934Medicaid
VA010222559Medicaid
TNQ006729Medicaid
VA015277R53Medicare PIN
VA010230934Medicaid
TNQ006729Medicaid
TN103I114766Medicare PIN