Basic Information
| Provider Information | |||||||||
| NPI: | 1215152236 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIRAGUSA | ||||||||
| FirstName: | TIF | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | 6158512018 | ||||||||
| Practice Location | |||||||||
| Address1: | 5651 FRIST BLVD | ||||||||
| Address2: | SUITE 414 | ||||||||
| City: | HERMITAGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370762054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158847600 | ||||||||
| FaxNumber: | 6158847799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 43966 | TN | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100348490 | 05 | KY | MEDICAID | 6022410 | 01 | TN | BCBS | OTHER | 1514975 | 05 | TN | MEDICAID |