Provider Demographics
NPI:1205881315
Name:MCMICHEN, JOHN WAYNE (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WAYNE
Last Name:MCMICHEN
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 1:109 COUNTY ROAD 1150
Mailing Address - Street 2:
Mailing Address - City:RICEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37370-5795
Mailing Address - Country:US
Mailing Address - Phone:423-525-7120
Mailing Address - Fax:
Practice Address - Street 1:6108 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4019
Practice Address - Country:US
Practice Address - Phone:865-539-9299
Practice Address - Fax:865-539-9701
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25941207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1507230Medicaid
TNP00643329OtherRAILROAD MEDICARE
TN4185180OtherBCBSTN THRU APPALACHIAN MED SVCS
TN4185180OtherBCBSTN THRU APPALACHIAN MED SVCS