Basic Information
| Provider Information | |||||||||
| NPI: | 1831293497 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VERHULST | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5000 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370885000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154442320 | ||||||||
| FaxNumber: | 6154493163 | ||||||||
| Practice Location | |||||||||
| Address1: | 2831 WILMA RUDOLPH BLVD | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370405002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312458600 | ||||||||
| FaxNumber: | 9312458660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 06/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 34111 | KY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 42702 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000696946 | 01 | KY | BCBS | OTHER | 64341118 | 05 | KY | MEDICAID | 3000647 | 05 | TN | MEDICAID | P00915988 | 01 | KY | RR MEDICARE | OTHER |