Basic Information
| Provider Information | |||||||||
| NPI: | 1124554068 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HUGHSTON CLINIC ORTHOPAEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 370 | ||||||||
| Address2: | |||||||||
| City: | FORTSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 318080370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063246661 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 HIGHWAY 70 E STE 103 | ||||||||
| Address2: | |||||||||
| City: | DICKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370552080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154551966 | ||||||||
| FaxNumber: | 6157400259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2017 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENCHWICK | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 7063246661 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | TN | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 0922510016 | 01 | TN | MEDICARE DME | OTHER | 3707844 | 05 | TN | MEDICAID |