1346288966 NPI number — CLYDE O SOUTHWELL MD

Table of content: CLYDE O SOUTHWELL MD (NPI 1346288966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346288966 NPI number — CLYDE O SOUTHWELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUTHWELL
Provider First Name:
CLYDE
Provider Middle Name:
O
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:
1346288966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3024 BUSINESS PARK CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOODLETTSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37072-3132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-239-2018
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 WESSINGTON PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSONVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37075-3085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-822-2214
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2006

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: 174400000X , with the licence number:  43085 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: 43085 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 43085 , 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: 5902491 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: N01356 . This is a "SC MEDICAID PROVIDER#" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 0404464 . This is a "EVERCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 14014 . This is a "BCBS PROVIDER#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 184386 . This is a "MEDCOST PROVIDER#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: FH2967215 . This is a "FCC PROVIDER#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00278679 . This is a "PALMETTO GBA PROVIDER#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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