Basic Information
| Provider Information | |||||||||
| NPI: | 1619976024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAHN | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | THEODORE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6350 W A J HWY | ||||||||
| Address2: | DEPARTMENT 100 | ||||||||
| City: | TALBOTT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003553565 | ||||||||
| FaxNumber: | 4237142355 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 ADESSA PKWY | ||||||||
| Address2: | SUITE A-150 | ||||||||
| City: | LENOIR CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377716725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659868082 | ||||||||
| FaxNumber: | 8659865890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 02/17/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD15926 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3012396 | 05 | TN | MEDICAID |