Basic Information
| Provider Information | |||||||||
| NPI: | 1578591756 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAURY REGIONAL HOSPITAL MARSHALL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARSHALL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 N ELLINGTON PKWY | ||||||||
| Address2: | P O BOX 1609 | ||||||||
| City: | LEWISBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370912227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313596241 | ||||||||
| FaxNumber: | 9312703627 | ||||||||
| Practice Location | |||||||||
| Address1: | 1080 N ELLINGTON PKWY | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370912227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313596241 | ||||||||
| FaxNumber: | 9312703627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRINKLEY | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9315404212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 0000000075 | TN | N | Hospital Units | Medicare Defined Swing Bed Unit | 282NC0060X | 0000000075 | TN | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 0441309 | 05 | TN | MEDICAID | 0410172 | 01 | TN | HEALTHSPRING | OTHER | 1000189 | 01 | TN | BLUE CROSS BLUE SHIELD TN | OTHER | 1000189 | 01 | TN | TENNCARE SELECT PROVIDER | OTHER |