Provider Demographics
NPI:1831126242
Name:MENA, MICHAEL C (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
Last Name:MENA
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 15628
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-0628
Mailing Address - Country:US
Mailing Address - Phone:423-870-2063
Mailing Address - Fax:423-870-2041
Practice Address - Street 1:2051 HAMILL RD
Practice Address - Street 2:SUITE 403
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-6606
Practice Address - Country:US
Practice Address - Phone:423-870-2063
Practice Address - Fax:423-870-2041
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000018148174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3027219Medicaid
TN0080988OtherBLUE CROSS BLUE SHIELD
TNTN101OtherJOHN DEERE
TN3027219Medicaid
TN3027219Medicare ID - Type Unspecified