Basic Information
| Provider Information | |||||||||
| NPI: | 1780618942 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TENNESSEE PHLEBOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2015 SPRING ROAD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307252759 | ||||||||
| FaxNumber: | 8774895987 | ||||||||
| Practice Location | |||||||||
| Address1: | 9020 OVERLOOK BLVD STE 150 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370272727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154017162 | ||||||||
| FaxNumber: | 6154017163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/05/2021 | ||||||||
| NPIReactivationDate: | 06/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 6307252737 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 208600000X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 202K00000X | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Phlebology |
No ID Information.