Provider Demographics
NPI:1992781751
Name:WILLIAMS, MICHAEL TYELAR (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TYELAR
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 HIGHWAY 39 E
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37329-5362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 S WHITE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-4732
Practice Address - Country:US
Practice Address - Phone:423-745-4322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD37798207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN38893201Medicaid
GA080012905BMedicaid
NC5904043Medicaid
TN4155984OtherBCBS
NC5904043Medicaid
TN38893201Medicare PIN
H94142Medicare UPIN