Healthcare Provider Details

I. General information

NPI: 1801891189
Provider Name (Legal Business Name): MICHAEL J BUCKMASTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 REID PKWY SUITE 215
RICHMOND IN
47374-1157
US

IV. Provider business mailing address

1100 REID PKWY MEDICAL STAFF SERVICES
RICHMOND IN
47374-1157
US

V. Phone/Fax

Practice location:
  • Phone: 765-939-9331
  • Fax: 765-939-9314
Mailing address:
  • Phone: 765-939-9331
  • Fax: 765-939-9314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01048422A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number35.090263
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number01048422A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: