Provider Demographics
NPI:1780624809
Name:DE BOER, MICHAEL H (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:H
Last Name:DE BOER
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 1:1431 CENTERPOINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-1984
Mailing Address - Country:US
Mailing Address - Phone:865-693-1000
Mailing Address - Fax:
Practice Address - Street 1:9352 PARK WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4325
Practice Address - Country:US
Practice Address - Phone:865-373-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46604207P00000X
TN19872207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN930005254OtherRRGA
TN4091370OtherBLUE CROSS
KY64043011Medicaid
TN3096096Medicaid