Basic Information
| Provider Information | |||||||||
| NPI: | 1548571482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TENNESSEE SPORTS MEDICINE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4998 CROSSINGS CIR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOUNT JULIET | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371220018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155535000 | ||||||||
| FaxNumber: | 6157583875 | ||||||||
| Practice Location | |||||||||
| Address1: | 4998 CROSSINGS CIR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOUNT JULIET | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371220018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155535000 | ||||||||
| FaxNumber: | 6157583875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2010 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | KAELIN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | ORTHOPAEDIC SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 6155535000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 025086 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1520487 | 05 | TN | MEDICAID | 3723564 | 01 | MEDICARE ID | OTHER |