Provider Demographics
NPI:1427118736
Name:TACHENKO, MICHAEL (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TACHENKO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2225
Mailing Address - Country:US
Mailing Address - Phone:423-892-5602
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:975 E. THIRD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-7608
Practice Address - Fax:423-778-2360
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN86105163W00000X
GARN099765163W00000X
TNAPN9675367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1513898Medicaid
TN3049738OtherBLUE CROSS BLUE SHIELD TN
NC8052358Medicaid
AL009710020Medicaid
TN430030831OtherRAILROAD MEDICARE
GAN361872OtherWELLCARE (GA MEDICAID)
GA000487473BMedicaid
NC8052358Medicaid