Basic Information
| Provider Information | |||||||||
| NPI: | 1063473346 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLY | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | RANDOLPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 HOSPITAL DR | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377605287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654754484 | ||||||||
| FaxNumber: | 8654751124 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 HOSPITAL DR | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377605287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654754484 | ||||||||
| FaxNumber: | 8654751124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 06/20/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 15794 | TN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | P01315239 | 01 | TN | RAILROAD MEDICARE | OTHER | Q001842 | 05 | TN | MEDICAID | 2577295 | 01 | CIGNA | OTHER | 200046272 | 01 | GA | RAILROAD MEDICARE | OTHER | 6004897 | 01 | TN | BLUECROSS BLUESHIELD | OTHER | 7962437 | 01 | TN | AETNA | OTHER |