Basic Information
| Provider Information | |||||||||
| NPI: | 1003823097 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLARKSVILLE HEALTH SYSTEM GP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GATEWAY HEALTH SYSTEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 403765 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303843765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315526622 | ||||||||
| FaxNumber: | 9315511027 | ||||||||
| Practice Location | |||||||||
| Address1: | 1771 MADISON ST | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370434990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315526622 | ||||||||
| FaxNumber: | 9315511027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 07/24/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HURLEY | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2144733993 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLARKSVILLE HEALTH SYSTEM GP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1003823097 | 05 | TN | MEDICAID |