Basic Information
| Provider Information | |||||||||
| NPI: | 1023140126 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TENNESSEE ORTHOPAEDIC ALLIANCE PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TENNESSEE OTHOPAEDIC ALLIANCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9118 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554809118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153292294 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 451 HIGHWAY 13 S | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371852109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153832693 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCONNELL | ||||||||
| AuthorizedOfficialFirstName: | ZENA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING TEAM LEAD | ||||||||
| AuthorizedOfficialTelephone: | 8652438152 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | CPC, CPCO, PESC | ||||||||
| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3372041 | 05 | TN | MEDICAID |