Basic Information
| Provider Information | |||||||||
| NPI: | 1194378083 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAURY REGIONAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COLUMBIA OB GYN PRIMARY CARE NETWORK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 617 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HOHENWALD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384621355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317964901 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1222 TROTWOOD AVE STE 603 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384016410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314901295 | ||||||||
| FaxNumber: | 9314901298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2019 | ||||||||
| LastUpdateDate: | 08/02/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAWSON | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 9314907019 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MAURY REGIONAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.