Provider Demographics
NPI:1447679881
Name:LAW, MICHELLE ELISA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELISA
Last Name:LAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 12TH AVE S APT 518
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-6645
Mailing Address - Country:US
Mailing Address - Phone:917-922-7825
Mailing Address - Fax:
Practice Address - Street 1:3443 DICKERSON PIKE STE 680
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37207
Practice Address - Country:US
Practice Address - Phone:615-865-3322
Practice Address - Fax:615-467-6692
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN579029208M00000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4114980OtherBLUE CROSS
TNQ036122Medicaid
KY7100550550Medicaid
KY7100364230Medicaid