Basic Information
| Provider Information | |||||||||
| NPI: | 1346530284 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIRBROTHER | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | WALTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 25TH AVE N STE 1204 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153120600 | ||||||||
| FaxNumber: | 6153203259 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 25TH AVE N STE 1204 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153120600 | ||||||||
| FaxNumber: | 6153203259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2011 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 56941 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | Q036873 | 05 | TN | MEDICAID |