Basic Information
| Provider Information | |||||||||
| NPI: | 1407878077 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEBANON DIGESTIVE DISEASE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PHYSICIANS WAY | ||||||||
| Address2: | STE 330 | ||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370908102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154496222 | ||||||||
| FaxNumber: | 6154531893 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PHYSICIANS WAY | ||||||||
| Address2: | STE 330 | ||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370908102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154496222 | ||||||||
| FaxNumber: | 6154531893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6154496222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | CMC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.