Provider Demographics
NPI:1720022130
Name:BEARB, MICHAEL EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWIN
Last Name:BEARB
Suffix:
Gender:M
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:PO BOX 3572
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38303-3572
Mailing Address - Country:US
Mailing Address - Phone:731-668-1853
Mailing Address - Fax:731-664-7731
Practice Address - Street 1:810 W FOREST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3942
Practice Address - Country:US
Practice Address - Phone:731-668-1853
Practice Address - Fax:731-664-7731
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24779207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3078790Medicaid
TNE13401Medicare UPIN
TN3078790Medicaid