1932177805 NPI number — CANONICO EAR, NOSE AND THROAT, P.C.

Table of content: (NPI 1932177805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932177805 NPI number — CANONICO EAR, NOSE AND THROAT, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANONICO EAR, NOSE AND THROAT, P.C.
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:
EAR, NOSE AND THROAT ASSOCIATES OF MIDDLE TENNESSEE, P.C.
Provider Other Organization Name Type Code:
4
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:
1932177805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
507 NW ATLANTIC ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULLAHOMA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37388-3504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-393-4332
Provider Business Mailing Address Fax Number:
931-393-2304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
507 NW ATLANTIC ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULLAHOMA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37388-3504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-393-4332
Provider Business Practice Location Address Fax Number:
931-393-2304
Provider Enumeration Date:
03/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOYERS
Authorized Official First Name:
TANDIE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
931-684-3504

Provider Taxonomy Codes

  • Taxonomy code: 207YX0007X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4064287 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3710667 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3710667 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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