Basic Information
| Provider Information | |||||||||
| NPI: | 1205859279 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEHARRY MEDICAL COLLEGE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEHARRY MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 DR. D. B. TODD BLVD | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153275592 | ||||||||
| FaxNumber: | 6153275555 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 DR. D. B. TODD BLVD | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153275592 | ||||||||
| FaxNumber: | 6153275555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 04/15/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ARNOLD | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 6153275509 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 3717679 | 05 | TN | MEDICAID |