Basic Information
| Provider Information | |||||||||
| NPI: | 1689614521 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARKRIDGE MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PARKRIDGE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 MCCALLIE AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374043258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236986061 | ||||||||
| FaxNumber: | 4234931208 | ||||||||
| Practice Location | |||||||||
| Address1: | 2333 MCCALLIE AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374043258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236986061 | ||||||||
| FaxNumber: | 4234931208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 09/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | ST. PIERRE | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4234931293 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PARKRIDGE MEDICAL CENTER, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 044T156 | 05 | TN | MEDICAID |