1194925487 NPI number — MICHELLE K DILKS DO

Table of content: MICHELLE K DILKS DO (NPI 1194925487)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194925487 NPI number — MICHELLE K DILKS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DILKS
Provider First Name:
MICHELLE
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194925487
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1406 TUSCULUM BLVD
Provider Second Line Business Mailing Address:
SUITE 1200A
Provider Business Mailing Address City Name:
GREENEVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37745-4332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-783-5520
Provider Business Mailing Address Fax Number:
423-783-5521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1406 TUSCULUM BLVD
Provider Second Line Business Practice Location Address:
SUITE 1200A
Provider Business Practice Location Address City Name:
GREENEVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37745-4332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-783-5520
Provider Business Practice Location Address Fax Number:
423-783-5521
Provider Enumeration Date:
07/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OS013484 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: DO0000002370 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Q009564 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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