Healthcare Provider Details

I. General information

NPI: 1316124894
Provider Name (Legal Business Name): MICHAEL DALTON HANOWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2008
Last Update Date: 08/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5126 HOSPITAL DR NE
COVINGTON GA
30014-2566
US

IV. Provider business mailing address

PO BOX 7096
STOCKTON CA
95267-0096
US

V. Phone/Fax

Practice location:
  • Phone: 770-385-4426
  • Fax:
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number001560
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number061846
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number061846
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: