Basic Information
| Provider Information | |||||||||
| NPI: | 1689860413 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCMINNVILLE EMERGENCY SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 532738 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303532738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048051300 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Practice Location | |||||||||
| Address1: | 1559 SPARTA ST | ||||||||
| Address2: | |||||||||
| City: | MC MINNVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371101316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9318154205 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2007 | ||||||||
| LastUpdateDate: | 09/14/2007 | ||||||||
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| AuthorizedOfficialLastName: | DRESNICK | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9048051300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3727294 | 05 | TN | MEDICAID |