Healthcare Provider Details

I. General information

NPI: 1114900131
Provider Name (Legal Business Name): MICHAEL BACKUES MSM, ATC, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 TROTWOOD AVE
COLUMBIA TN
38401-4802
US

IV. Provider business mailing address

1224 TROTWOOD AVE
COLUMBIA TN
38401-4802
US

V. Phone/Fax

Practice location:
  • Phone: 931-381-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number627
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2267
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: