Basic Information
Provider Information | |||||||||
NPI: | 1508973819 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCLINTIC | ||||||||
FirstName: | EUGENE | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 MEDICAL PARK BLVD | ||||||||
Address2: | 250 WEST | ||||||||
City: | BRISTOL | ||||||||
State: | TN | ||||||||
PostalCode: | 376207431 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238446620 | ||||||||
FaxNumber: | 4238446626 | ||||||||
Practice Location | |||||||||
Address1: | 1 MEDICAL PARK BLVD | ||||||||
Address2: | 250 WEST | ||||||||
City: | BRISTOL | ||||||||
State: | TN | ||||||||
PostalCode: | 376207430 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238446620 | ||||||||
FaxNumber: | 4238446626 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2006 | ||||||||
LastUpdateDate: | 09/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD0000024575 | TN | N |   | Other Service Providers | Specialist |   | 208600000X | 24575 | TN | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | ANTHEM | 01 | VA | 038614 | OTHER | 162576 | 01 | TN | TN BC | OTHER | 4545327 | 01 | TN | AETNA | OTHER | 007345747 | 05 | VA |   | MEDICAID | 3385580 | 05 | TN |   | MEDICAID |