1700075421 NPI number — TENNESSEE SPORTS MEDICINE & ORTHOPAEDICS, PC

Table of content: (NPI 1700075421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700075421 NPI number — TENNESSEE SPORTS MEDICINE & ORTHOPAEDICS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENNESSEE SPORTS MEDICINE & 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:
6
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:
1700075421
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1427 W BADDOUR PKWY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37087-2513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-443-7700
Provider Business Mailing Address Fax Number:
615-443-7200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1427 W BADDOUR PKWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37087-2513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-443-7700
Provider Business Practice Location Address Fax Number:
615-443-7200
Provider Enumeration Date:
10/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KAELIN
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
OWNER/MD
Authorized Official Telephone Number:
615-443-7700

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3723654 . This is a "MEDICARE GROUP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3080388 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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