Basic Information
| Provider Information | |||||||||
| NPI: | 1770562142 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TULLAHOMA PEDIATRICS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1327 | ||||||||
| Address2: | |||||||||
| City: | TULLAHOMA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373881327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314552674 | ||||||||
| FaxNumber: | 9314557594 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 CEDAR LN | ||||||||
| Address2: | BLDG B SUITE 900 | ||||||||
| City: | TULLAHOMA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373882283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314552674 | ||||||||
| FaxNumber: | 9314557594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | TUCK | ||||||||
| AuthorizedOfficialFirstName: | CAROLINE | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9314552674 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 2084P0804X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.