Basic Information
Provider Information | |||||||||
NPI: | 1255866711 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TENNESSEE ORTHOPAEDIC ALLIANCE, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 608 NORRIS AVE | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372043708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6156951432 | ||||||||
FaxNumber: | 6156951483 | ||||||||
Practice Location | |||||||||
Address1: | 315 N WASHINGTON AVE | ||||||||
Address2: | SUITE 150 | ||||||||
City: | COOKEVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 385012603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9315256676 | ||||||||
FaxNumber: | 6152971449 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2017 | ||||||||
LastUpdateDate: | 04/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SIMMONS | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6156951432 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0406260014 | 01 | TN | PALMETTO DME PTAN | OTHER | 3372041 | 05 | TN |   | MEDICAID |