Basic Information
| Provider Information | |||||||||
| NPI: | 1336166388 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY PHYSICIANS OF MONTGOMERY COUNTY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 CRESCENT CENTRE DR | ||||||||
| Address2: | STE 140 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370674688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152690652 | ||||||||
| FaxNumber: | 6152690135 | ||||||||
| Practice Location | |||||||||
| Address1: | 651 DUNLOP LN | ||||||||
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| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370405015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315021370 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | DUKE | ||||||||
| AuthorizedOfficialFirstName: | HAROLD | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6152690652 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3734849 | 05 | TN | MEDICAID |