Basic Information
Provider Information | |||||||||
NPI: | 1528022019 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRUIN | ||||||||
FirstName: | ALEX | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 53 CENTURY BLVD | ||||||||
Address2: | SUITE 120 | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372143693 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153466213 | ||||||||
FaxNumber: | 6152925722 | ||||||||
Practice Location | |||||||||
Address1: | 3901 CENTRAL PIKE | ||||||||
Address2: | SUITE 555 | ||||||||
City: | HERMITAGE | ||||||||
State: | TN | ||||||||
PostalCode: | 370763419 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6158749667 | ||||||||
FaxNumber: | 6158719682 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2006 | ||||||||
LastUpdateDate: | 04/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD0000039848 | TN | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 7085723 | 01 |   | AETNA | OTHER | 1507577 | 05 | TN |   | MEDICAID | 2640111 | 01 |   | CIGNA | OTHER | 4195507 | 01 |   | BLUE CROSS BLUE SHIELD | OTHER |