Basic Information
| Provider Information | |||||||||
| NPI: | 1306036769 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENDERSONVILLE OBGYN LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BLUEGRASS OBSTETRICS AND GYNECOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 NEW SHACKLE ISLAND RD | ||||||||
| Address2: | SUITE 341-C | ||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370752379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158261716 | ||||||||
| FaxNumber: | 6158264841 | ||||||||
| Practice Location | |||||||||
| Address1: | 353 NEW SHACKLE ISLAND RD | ||||||||
| Address2: | SUITE 341-C | ||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370752379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158261716 | ||||||||
| FaxNumber: | 6158264841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | LOCKE | ||||||||
| AuthorizedOfficialFirstName: | CHUCK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153737604 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 3723252 | 05 | TN | MEDICAID |