Basic Information
| Provider Information | |||||||||
| NPI: | 1760801526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TANAVIN | ||||||||
| FirstName: | TOUG | ||||||||
| MiddleName: | MARK | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TONARTTANAVIN | ||||||||
| OtherFirstName: | TOUG | ||||||||
| OtherMiddleName: | MARK | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 353 NEW SHACKLE ISLAND RD STE 300C | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370752384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158240043 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 353 NEW SHACKLE ISLAND RD STE 300C | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370752384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158240043 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2014 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | BP10049487 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0011X | 63496 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.