Basic Information
| Provider Information | |||||||||
| NPI: | 1700837341 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDDLE TENNESSEE UROLOGY ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 854 W JAMES CAMPBELL BLVD | ||||||||
| Address2: | SUITE 303B | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384014659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315404255 | ||||||||
| FaxNumber: | 9314904654 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 TROTWOOD AVE | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384016436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9318405088 | ||||||||
| FaxNumber: | 9318405086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | HEFFINGTON | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9318405088 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 3725470 | 05 | TN | MEDICAID |