Basic Information
Provider Information | |||||||||
NPI: | 1770035214 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GATEWAY HEALTHCARE, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1574 MEDICAL CENTER PKWY | ||||||||
Address2: | SUITE 104 | ||||||||
City: | MURFREESBORO | ||||||||
State: | TN | ||||||||
PostalCode: | 371293760 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6152252070 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1574 MEDICAL CENTER PKWY | ||||||||
Address2: | SUITE 104 | ||||||||
City: | MURFREESBORO | ||||||||
State: | TN | ||||||||
PostalCode: | 371293760 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6152252070 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2016 | ||||||||
LastUpdateDate: | 05/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEATHERSBY | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | SETH | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PROVIDER | ||||||||
AuthorizedOfficialTelephone: | 6152252070 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PA-C | ||||||||
NPICertificationDate: | 05/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 1879 | TN | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
ID | Type | State | Issuer | Description | 1013 | 01 | TN | STATE OF TENNESSEE DEPT OF HEALTH | OTHER |