Basic Information
| Provider Information | |||||||||
| NPI: | 1033223896 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL TENNESSEE EAR NOSE & THROAT | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 787 WEATHERLY DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370438949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9316471255 | ||||||||
| FaxNumber: | 9316472399 | ||||||||
| Practice Location | |||||||||
| Address1: | 787 WEATHERLY DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370438949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9316471255 | ||||||||
| FaxNumber: | 9316472399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | FOUST | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9316471255 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD0000021029 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 6039651 | 01 | BLUECROSS | OTHER | 1524504 | 05 | TN | MEDICAID | 621860059 | 01 | TN | TRICARE | OTHER |