Basic Information
| Provider Information | |||||||||
| NPI: | 1497744767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067433150 | ||||||||
| FaxNumber: | 8067433168 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794309410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067433150 | ||||||||
| FaxNumber: | 8067433168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | K5662 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100149890A | 05 | OK | MEDICAID | 68807 | 05 | NM | MEDICAID | A451 | 01 | NM | TRIWEST | OTHER | 66398 | 05 | NM | MEDICAID | 68807 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | 84304Z | 01 | TX | HMO BLUE | OTHER | 88178G | 01 | TX | BC/BS | OTHER | 118516701 | 05 | TX | MEDICAID | 121479101 | 05 | TX | MEDICAID | 121479103 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER |