Provider Demographics
NPI:1780628891
Name:BACON, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:BACON
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 11724
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37939-1724
Mailing Address - Country:US
Mailing Address - Phone:865-766-8800
Mailing Address - Fax:865-766-8874
Practice Address - Street 1:130 WEST RAVINE ROAD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37662
Practice Address - Country:US
Practice Address - Phone:423-224-4000
Practice Address - Fax:423-224-5120
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23688207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3072071Medicaid
TN3072072Medicare PIN
TN3072071Medicaid