Basic Information
| Provider Information | |||||||||
| NPI: | 1508930249 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEFFREY A LARSEN MD PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JEFFREY A LARSEN MD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 STONECREST BLVD | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | SMYRNA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371676818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152239935 | ||||||||
| FaxNumber: | 6157687871 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 STONECREST BLVD | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | SMYRNA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371676818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152239935 | ||||||||
| FaxNumber: | 6157687871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 10/01/2007 | ||||||||
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| AuthorizedOfficialLastName: | LARSEN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | ARTHUR | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6152239935 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 30866 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3836764 | 05 | TN | MEDICAID |