Basic Information
| Provider Information | |||||||||
| NPI: | 1184610859 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UPPER CUMBERLAND ORTHOPEDIC SURGERY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 S. WILLOW AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315269518 | ||||||||
| FaxNumber: | 9313720087 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 S. WILLOW AVE. | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315269518 | ||||||||
| FaxNumber: | 9313720087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | EASTERLY | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9313727716 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204C00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 65942575 | 05 | KY | MEDICAID | 3704956 | 05 | TN | MEDICAID |