Basic Information
| Provider Information | |||||||||
| NPI: | 1548223084 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THEERATHORN | ||||||||
| FirstName: | PITCHAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3889 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376023889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237942457 | ||||||||
| FaxNumber: | 4232839480 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 MED TECH PKWY STE 240 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945520 | ||||||||
| FaxNumber: | 4232826940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 05/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 26545 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 35127 | TN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 35127 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3877775 | 05 | TN | MEDICAID | 279422500 | 05 | FL | MEDICAID | 562173631 | 01 | SC | TAX ID | OTHER |