=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538140207
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY ALEXANDER MICHEL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2005
-----------------------------------------------------
Last Update Date | 03/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9040 JACKSON AVENUE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98431-4746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-968-2130
-----------------------------------------------------
Fax | 253-968-3140
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2114 LAFAYETTE ST
-----------------------------------------------------
City | STEILACOOM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98388-1346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-481-4705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD00036387
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | MD00036387
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | MD00036387
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------