Basic Information
| Provider Information | |||||||||
| NPI: | 1629295738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUNNEBACKE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 587 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314248922 | ||||||||
| FaxNumber: | 7314232922 | ||||||||
| Practice Location | |||||||||
| Address1: | 587 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314248922 | ||||||||
| FaxNumber: | 7314232922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207R00000X | MD011299 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3182200 | 05 | TN | MEDICAID |