1154581437 NPI number — TOMMY DALE LIVESAY MD

Table of content: MARCELLO IMMEDIATO-SCUOTTO DO (NPI 1952191306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154581437 NPI number — TOMMY DALE LIVESAY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIVESAY
Provider First Name:
TOMMY
Provider Middle Name:
DALE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1154581437
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 NETTLETON RD STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARROGATE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37752-8225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-419-5550
Provider Business Mailing Address Fax Number:
423-419-5551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 NETTLETON RD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARROGATE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37752-8225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-419-5550
Provider Business Practice Location Address Fax Number:
234-195-5514
Provider Enumeration Date:
06/11/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0101250073 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 44663 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 47578 , 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: 1525167 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100185130 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1932488327 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".