Basic Information
Provider Information | |||||||||
NPI: | 1124067533 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANGRUM | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 104 WOODMONT BLVD | ||||||||
Address2: | SUITE LL50 | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372052245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153862300 | ||||||||
FaxNumber: | 6153862399 | ||||||||
Practice Location | |||||||||
Address1: | 4230 HARDING RD | ||||||||
Address2: | SUITE 400 | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372052013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6152972700 | ||||||||
FaxNumber: | 6152694584 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2006 | ||||||||
LastUpdateDate: | 05/07/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 27482 | TN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X | 027482 | TN | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 01047325 | 01 | TN | AMERIGROUP-MCD | OTHER | 2790831 | 01 | TN | COVENTRY/FIRST HEALTH | OTHER | P00103889 | 01 | TN | MEDICARE RR | OTHER | 1735352 | 01 | TN | UNITED HEALTH CARE | OTHER | 4085154 | 01 | TN | BLUE CROSS OF TN | OTHER | 2790831 | 01 | TN | CIGNA PPO, POS | OTHER | 12459471 | 01 | TN | MULTIPLAN/PHCS | OTHER | 3801962 | 05 | TN |   | MEDICAID | 5389663 | 01 | TN | AETNA | OTHER | 549809 | 01 | TN | USA - MCO | OTHER | 71000102000 | 05 | KY |   | MEDICAID |