Healthcare Provider Details

I. General information

NPI: 1154513364
Provider Name (Legal Business Name): MICHAEL JOHN AUSTEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2007
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 MANATEE AVE W
BRADENTON FL
34209-3816
US

IV. Provider business mailing address

367 S. GULPH RD ATT IPM CREDENTIALING
KING OF PRUSSIA PA
19406-3121
US

V. Phone/Fax

Practice location:
  • Phone: 941-745-5999
  • Fax: 941-745-3555
Mailing address:
  • Phone: 775-356-9393
  • Fax: 775-356-5590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME118122
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: