1124067533 NPI number — TIMOTHY C MANGRUM M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124067533 NPI number — TIMOTHY C MANGRUM M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MANGRUM

Provider First Name:

TIMOTHY

Provider Middle Name:

C

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1124067533

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

05/07/2015

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

104 WOODMONT BLVD

Provider Second Line Business Mailing Address:

SUITE LL50

Provider Business Mailing Address City Name:

NASHVILLE

Provider Business Mailing Address State Name:

TN

Provider Business Mailing Address Postal Code:

37205-2245

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

615-386-2300

Provider Business Mailing Address Fax Number:

615-386-2399

Provider First Line Business Practice Location Address:

4230 HARDING RD

Provider Second Line Business Practice Location Address:

SUITE 400

Provider Business Practice Location Address City Name:

NASHVILLE

Provider Business Practice Location Address State Name:

TN

Provider Business Practice Location Address Postal Code:

37205-2013

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

615-297-2700

Provider Business Practice Location Address Fax Number:

615-269-4584

Provider Enumeration Date:

06/05/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  27482 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 208000000X , with the licence number: 027482 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 01047325 . This is a "AMERIGROUP-MCD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 2790831 . This is a "COVENTRY/FIRST HEALTH" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: P00103889 . This is a "MEDICARE RR" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 1735352 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 4085154 . This is a "BLUE CROSS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 2790831 . This is a "CIGNA PPO, POS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 12459471 . This is a "MULTIPLAN/PHCS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 3801962 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
• Identifier: 5389663 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 549809 . This is a "USA - MCO" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 71000102000 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".