1609062363 NPI number — DR. JEFFREY A LARSEN MD

Table of content: DR. JEFFREY A LARSEN MD (NPI 1609062363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609062363 NPI number — DR. JEFFREY A LARSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSEN
Provider First Name:
JEFFREY
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
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:
LARSEN
Provider Other First Name:
JEFFREY
Provider Other Middle Name:
ARTHUR
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1609062363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 STONECREST BLVD
Provider Second Line Business Mailing Address:
SUITE 360
Provider Business Mailing Address City Name:
SMYRNA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37167-6818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-223-9935
Provider Business Mailing Address Fax Number:
615-768-7871

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 STONECREST BLVD
Provider Second Line Business Practice Location Address:
SUITE 360
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37167-6818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-223-9935
Provider Business Practice Location Address Fax Number:
615-768-2021
Provider Enumeration Date:
09/17/2007

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: 208600000X , with the licence number:  30866 , 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: 1529941 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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