1700274487 NPI number — PLATEAU MEDICAL SPECIALIST PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700274487 NPI number — PLATEAU MEDICAL SPECIALIST PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLATEAU MEDICAL SPECIALIST 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:
STEVEN PRIBANICH, M.D.
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:
1700274487
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
848 LIVINGSTON RD
Provider Second Line Business Mailing Address:
SUITE 101, PMB #49
Provider Business Mailing Address City Name:
CROSSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38555-6740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-484-7675
Provider Business Mailing Address Fax Number:
931-484-3045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57 W ADAMS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROSSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38555-4836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-484-7675
Provider Business Practice Location Address Fax Number:
931-484-3045
Provider Enumeration Date:
01/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PRIBANICH
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
931-484-7675

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X , with the licence number:  34621 , 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)





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