Basic Information
| Provider Information | |||||||||
| NPI: | 1508069824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRANSSOUTH HEALTH CARE PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | TRANSSOUTH HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11567 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316619977 | ||||||||
| FaxNumber: | 7316649376 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 WEATHERFORD SQ | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316619977 | ||||||||
| FaxNumber: | 7316649376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 03/03/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOUDER | ||||||||
| AuthorizedOfficialFirstName: | BOB | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES CEO AND OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7316610086 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRANSSOUTH HEALTH CARE PC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 3306 | TN | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 3704351 | 05 | TN | MEDICAID |