Basic Information
| Provider Information | |||||||||
| NPI: | 1659326700 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLARKSVILLE HEALTH SYSTEM GP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TENNOVA HEALTHCARE-CLARKSVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 403765 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303843765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315526622 | ||||||||
| FaxNumber: | 9315511027 | ||||||||
| Practice Location | |||||||||
| Address1: | 651 DUNLOP LN | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370405015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315021000 | ||||||||
| FaxNumber: | 9315021215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LALOR | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6292153953 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLARKSVILLE HEALTH SYSTEM GP | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 000000090 | TN | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 1000156 | 05 | TN | MEDICAID |