Provider Demographics
NPI:1538280755
Name:TUCKER, MICHELLE LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEIGH
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:RAND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1351 CRESTVIEW ROAD
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642
Mailing Address - Country:US
Mailing Address - Phone:864-855-5006
Mailing Address - Fax:864-855-0240
Practice Address - Street 1:1351 CRESTVIEW ROAD
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642
Practice Address - Country:US
Practice Address - Phone:864-855-5006
Practice Address - Fax:864-850-1992
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL27098207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC270986Medicaid
SCAA32117265Medicare PIN
SC270986Medicaid