Basic Information
| Provider Information | |||||||||
| NPI: | 1124005145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALTENBERN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 CHARLOTTE AVE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372094035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152509200 | ||||||||
| FaxNumber: | 6152509251 | ||||||||
| Practice Location | |||||||||
| Address1: | 395 WALLACE RD | ||||||||
| Address2: | STE 206B | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372114881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153318281 | ||||||||
| FaxNumber: | 6153313043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD21659 | TN | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 340013309 | 01 | TN | RR MEDICARE | OTHER | 64799521 | 05 | KY | MEDICAID | 3060807 | 05 | TN | MEDICAID | 0127086 | 01 | TN | BLUE CROSS | OTHER |