Basic Information
| Provider Information | |||||||||
| NPI: | 1811364250 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 SPARKS AVE STE 402 | ||||||||
| Address2: | |||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471303739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025878000 | ||||||||
| FaxNumber: | 5025878001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2015 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2018 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | TC415 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA2018 | 01 | KY | LICENSE | OTHER | 10003290A | 01 | IN | LICENSE | OTHER | 7100383320 | 05 | KY | MEDICAID |