Basic Information
Provider Information | |||||||||
NPI: | 1417138512 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BIRD | ||||||||
FirstName: | MARTHA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 699 | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | TN | ||||||||
PostalCode: | 376840699 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234398000 | ||||||||
FaxNumber: | 4234392200 | ||||||||
Practice Location | |||||||||
Address1: | BUILDING 52, LAKE DRIVE | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | TN | ||||||||
PostalCode: | 37684 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234398000 | ||||||||
FaxNumber: | 4234392200 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2007 | ||||||||
LastUpdateDate: | 08/22/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 45132 | TN | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 45132 | TN | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 3714470 | 01 | TN | GROUP TN MEDICARE NUMBER | OTHER |