Basic Information
| Provider Information | |||||||||
| NPI: | 1548563406 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDTOWN HEALTHCARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4295 CROMWELL RD | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374212166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237027567 | ||||||||
| FaxNumber: | 4238775855 | ||||||||
| Practice Location | |||||||||
| Address1: | 709 WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374021916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238772312 | ||||||||
| FaxNumber: | 4238775855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2010 | ||||||||
| LastUpdateDate: | 10/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | RUSSELL | ||||||||
| AuthorizedOfficialFirstName: | KILEY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER - CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4237027548 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 44115 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.