Basic Information
| Provider Information | |||||||||
| NPI: | 1245275254 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT THOMAS HICKMAN HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ASCENSION SAINT THOMAS HICKMAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 135 E SWAN ST | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370331417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317294271 | ||||||||
| FaxNumber: | 9317290174 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 E SWAN ST | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370331417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317294271 | ||||||||
| FaxNumber: | 9317290174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAMPBELL | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 9317296790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | N | Hospital Units | Medicare Defined Swing Bed Unit | 282NC0060X | 0000000056 | TN | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 3280568 | 01 | TN | MEDICARE PTAN | OTHER | 0441300 | 05 | TN | MEDICAID | 1000133 | 01 | TN | BLUE CROSS | OTHER | 441300 | 01 | TN | MEDICARE INPATIENT | OTHER | 44Z300 | 01 | TN | MEDICARE SWINGBED | OTHER | 044Z300 | 05 | TN | MEDICAID |