Provider Demographics
NPI:1104814797
Name:ALLISON, MICHAEL GARY (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GARY
Last Name:ALLISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 WEST AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-5107
Mailing Address - Country:US
Mailing Address - Phone:931-456-4433
Mailing Address - Fax:931-456-4405
Practice Address - Street 1:421 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555
Practice Address - Country:US
Practice Address - Phone:931-484-9511
Practice Address - Fax:931-456-4405
Is Sole Proprietor?:No
Enumeration Date:2005-10-09
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-006810L207LP2900X
MS18895207LP2900X
NY188099207LP2900X
OH6347207LP2900X
TN1974207LP2900X
PA188099207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01715897Medicaid
PA0016134270002Medicaid
E79119Medicare UPIN
PA688132Medicare ID - Type Unspecified