Healthcare Provider Details

I. General information

NPI: 1174514624
Provider Name (Legal Business Name): MICHELLE D FISCUS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 02/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W BURTON ST
MURFREESBORO TN
37130-3657
US

IV. Provider business mailing address

710 JAMES ROBERTSON PKWY 8TH FLOOR
NASHVILLE TN
37243-1219
US

V. Phone/Fax

Practice location:
  • Phone: 615-898-7880
  • Fax:
Mailing address:
  • Phone: 615-532-6944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29141
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3122477
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: