Provider Demographics
NPI:1457367302
Name:CHUPP, MICHAEL E (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:CHUPP
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 1:312 MIA DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7246
Mailing Address - Country:US
Mailing Address - Phone:423-366-6005
Mailing Address - Fax:
Practice Address - Street 1:312 MIA DR
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7246
Practice Address - Country:US
Practice Address - Phone:423-366-6005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060968208600000X
TN0000055171208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1457367302Medicaid
F59723Medicare UPIN
MIMI2051017Medicare PIN