1891733093 NPI number — MR. JEFFREY PAUL SODEMANN PHYSICAL THERAPIST

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 1891733093 NPI number — MR. JEFFREY PAUL SODEMANN PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SODEMANN
Provider First Name:
JEFFREY
Provider Middle Name:
PAUL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
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:
1891733093
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1043 EXECUTIVE DRIVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
HIXSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37343-3998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-870-6004
Provider Business Mailing Address Fax Number:
423-870-6005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1043 EXECUTIVE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
HIXSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37343-3998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-870-6004
Provider Business Practice Location Address Fax Number:
423-870-6005
Provider Enumeration Date:
06/02/2006

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: 225100000X , with the licence number:  PT0000000341 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: PT000554 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3110918 . This is a "BLUECROSS BLUESHILD OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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