Basic Information
| Provider Information | |||||||||
| NPI: | 1376025114 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHCREST MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 305172 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372305172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153841571 | ||||||||
| FaxNumber: | 6153825776 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 NORTHCREST DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153842411 | ||||||||
| FaxNumber: | 6153825776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2018 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6153842411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 0000000099 | TN | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 0440065 | 05 | TN | MEDICAID |