Basic Information
| Provider Information | |||||||||
| NPI: | 1780866483 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TENN SM, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TENNESSEE SPORTS MEDICINE & ORTHOPAEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 300 STONECREST BLVD | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | SMYRNA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371675688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155535500 | ||||||||
| FaxNumber: | 6155535501 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 STONECREST BLVD | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | SMYRNA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371675688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155535500 | ||||||||
| FaxNumber: | 6155535501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2007 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KAELIN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/M.D. | ||||||||
| AuthorizedOfficialTelephone: | 6155535500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3723235 | 01 | GROUP MEDICARE NUMBER | OTHER |