MEDICARE: MICHAEL S PANKOW D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	0104000747	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	059152	OTHER	VA	BCBS

General Provider Information

NPI Number	:	1750376927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL S PANKOW D.C.

Provider Business Mailing Address
First Line	:	2000 GENERAL BOOTH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5876
Country	:	US
Telephone Number	:	757-490-0990
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 GENERAL BOOTH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5876
Country	:	US
Telephone Number	:	757-490-0990
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	03/12/2012

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