1447202452 NPI number — TENNESSEE VALLEY ANESTHESIA PLLC

Table of content: (NPI 1447202452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447202452 NPI number — TENNESSEE VALLEY ANESTHESIA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENNESSEE VALLEY ANESTHESIA PLLC
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:
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 Information

NPI Number:
1447202452
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5483 W WATERS AVE STE 1200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33634-1236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-287-5718
Provider Business Mailing Address Fax Number:
813-287-5728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 N MEADOWS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37303-4172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-649-3330
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FAHEY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF MANAGER
Authorized Official Telephone Number:
423-618-3448

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DD2592 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3729421 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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