1215154109 NPI number — PEERLESS MEDICAL ASSOCIATES

Table of content: (NPI 1215154109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215154109 NPI number — PEERLESS MEDICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEERLESS MEDICAL ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GARVIN K CHASTAIN MD
Provider Other Organization Name Type Code:
3
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 Information

NPI Number:
1215154109
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1060 PEERLESS CROSSING DR
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1060 PEERLESS CROSSING DR
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-479-4165
Provider Business Practice Location Address Fax Number:
423-478-1884
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FAULKNER
Authorized Official First Name:
CATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
423-479-4165

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  MD16293 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4439863 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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