Basic Information
| Provider Information | |||||||||
| NPI: | 1790811222 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NASHVILLE GASTROENTEROLOGY AND HEPATOLOGY, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SOUTHERN ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 330 WALLACE RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372114893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153905053 | ||||||||
| FaxNumber: | 6158325713 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 WALLACE RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372114893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153905053 | ||||||||
| FaxNumber: | 6158325713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 08/10/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | FALEECIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6153905053 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NASHVILLE GSSTROENTEROLOGY AND HEPATOLOGY, PC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 490001101 | 01 | TN | RAILROAD MEDICARE PIN | OTHER |