Healthcare Provider Details

I. General information

NPI: 1205367398
Provider Name (Legal Business Name): MR. MICHAEL SCOTT STILL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

IV. Provider business mailing address

5323 HARRY HINES BLVD
DALLAS TX
75390-9087
US

V. Phone/Fax

Practice location:
  • Phone: 817-702-1173
  • Fax:
Mailing address:
  • Phone: 214-645-9729
  • Fax: 214-645-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberS3933
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: