Basic Information
| Provider Information | |||||||||
| NPI: | 1013905710 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRANSSOUTH HEALTHCARE PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LEXINGTON MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11567 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383080126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316610086 | ||||||||
| FaxNumber: | 7316619702 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 E CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383511821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319680146 | ||||||||
| FaxNumber: | 7319689398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 02/15/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOUDER | ||||||||
| AuthorizedOfficialFirstName: | BOB | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7316610086 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 3704357 | 01 | CIGNA | OTHER | 3704357 | 05 | TN | MEDICAID |