Provider Demographics
NPI:1205947249
Name:TUCKER, MICHAEL C (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:TUCKER
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 22265
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4473
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:14 RICHLAND MEDICAL PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6882
Practice Address - Country:US
Practice Address - Phone:803-296-7846
Practice Address - Fax:803-296-9699
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039968207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000655157AMedicaid
SCG39968Medicaid
SCG39968Medicaid
G01427Medicare UPIN