Basic Information
| Provider Information | |||||||||
| NPI: | 1669447140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIND | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3098 | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370433098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9316475034 | ||||||||
| FaxNumber: | 9315526663 | ||||||||
| Practice Location | |||||||||
| Address1: | 651 DUNLOP LN | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370405015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315021000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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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 | 174400000X | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2005719 | 01 | BCBS | OTHER | 4034357 | 01 | TN | BCBS CIC | OTHER | 300069598 | 01 | RAILROAD MEDICARE | OTHER | 300139052 | 01 | RAILROAD MEDICARE CIC | OTHER | 3197361 | 05 | TN | MEDICAID |