Healthcare Provider Details

I. General information

NPI: 1326713272
Provider Name (Legal Business Name): REGENERATIVE PHYSIATRIST PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 10/09/2022
Certification Date: 10/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 MCKEE RD
DOVER DE
19904-1381
US

IV. Provider business mailing address

9623 PORTOFINO DR
BRENTWOOD TN
37027-3829
US

V. Phone/Fax

Practice location:
  • Phone: 302-672-5800
  • Fax:
Mailing address:
  • Phone: 615-589-6222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MATTHEW G. MICHAELS
Title or Position: CEO
Credential: MD
Phone: 615-589-6222