Basic Information
Provider Information | |||||||||
NPI: | 1699969097 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NASHVILLE SPORTS MEDICINE AND ORTHOPAEDIC CENTER PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NASHVILLE SPORTS MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2004 HAYES ST STE 700 | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372035178 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6152845800 | ||||||||
FaxNumber: | 6152845819 | ||||||||
Practice Location | |||||||||
Address1: | 2004 HAYES ST STE 700 | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372035178 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6152845800 | ||||||||
FaxNumber: | 6152845819 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2007 | ||||||||
LastUpdateDate: | 07/24/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHITTEN | ||||||||
AuthorizedOfficialFirstName: | JESSICA | ||||||||
AuthorizedOfficialMiddleName: | N | ||||||||
AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 6157600877 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/24/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 17901 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 374061900 | 01 |   | OWCP | OTHER | 4146164 | 01 | TN | BCBST | OTHER |