Provider Demographics
NPI:1932296373
Name:DOUGLAS, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DOUGLAS
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 1:1920 GUNBARREL RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3100
Mailing Address - Country:US
Mailing Address - Phone:423-899-5241
Mailing Address - Fax:423-894-7312
Practice Address - Street 1:1920 GUNBARREL RD
Practice Address - Street 2:SUITE 110
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3100
Practice Address - Country:US
Practice Address - Phone:423-899-5241
Practice Address - Fax:423-894-7312
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000010743207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3149708OtherBLUE CROSS BLUE SHEILD
TNB03227Medicare UPIN
TN3149708OtherBLUE CROSS BLUE SHEILD
TN3724279Medicare ID - Type UnspecifiedGROUP #