1184683179 NPI number — PETTY ORTHOPAEDICS PC

Table of content: (NPI 1598982662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184683179 NPI number — PETTY ORTHOPAEDICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETTY ORTHOPAEDICS PC
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:
1184683179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1616 W MAIN ST STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37087-3101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-443-7374
Provider Business Mailing Address Fax Number:
615-443-5488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1616 W. MAIN ST.
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-443-7374
Provider Business Practice Location Address Fax Number:
615-443-5488
Provider Enumeration Date:
03/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETTY
Authorized Official First Name:
DAMON
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
615-443-7374

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3732245 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1861452195 . This is a "MEDICARE NPI" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3732245 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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