Basic Information
| Provider Information | |||||||||
| NPI: | 1710919980 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UPPER CUMBERLAND ANESTHESIA ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 280 | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385030280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315287877 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385014294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315285587 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | LANDRY | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | HARRISON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9315287877 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207LP2900X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | CD2499 | 01 | MEDICARE RAILROAD | OTHER | 74904152 | 05 | KY | MEDICAID | 65945206 | 05 | KY | MEDICAID |