Basic Information
| Provider Information | |||||||||
| NPI: | 1831281963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAHL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 VIRGINIA WAY | ||||||||
| Address2: | STE 300 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152214474 | ||||||||
| FaxNumber: | 6152343774 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 VIRGINIA WAY | ||||||||
| Address2: | STE 300 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152214474 | ||||||||
| FaxNumber: | 6152343774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 9536 | TN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 18591 | KY | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 119361 | 01 | TN | UNISON TENNCARE | OTHER | 0053759 | 01 | TN | BLUE CROSS | OTHER | 64777030 | 05 | KY | MEDICAID | 1218779 | 05 | OH | MEDICAID | 3041804 | 05 | TN | MEDICAID | 89063HH | 05 | NC | MEDICAID | 000000001589 | 01 | TN | TLC TENNCARE | OTHER |