Basic Information
Provider Information | |||||||||
NPI: | 1841438579 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VOYTIK CENTER FOR ORTHOPEDIC CARE, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2700 WESTSIDE DR NW | ||||||||
Address2: | SUITE 301 | ||||||||
City: | CLEVELAND | ||||||||
State: | TN | ||||||||
PostalCode: | 373123699 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234793600 | ||||||||
FaxNumber: | 4233031234 | ||||||||
Practice Location | |||||||||
Address1: | 164 WALNUT GROVE CHURCH RD | ||||||||
Address2: |   | ||||||||
City: | DAYTON | ||||||||
State: | TN | ||||||||
PostalCode: | 37321 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234793600 | ||||||||
FaxNumber: | 4233031234 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/03/2009 | ||||||||
LastUpdateDate: | 02/03/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAUN | ||||||||
AuthorizedOfficialFirstName: | BEVERLY | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4233033560 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | VOYTIK CENTER FOR ORTHOPEDIC CARE, PC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPC, CMOM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PAC1237 | TN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 207X00000X | DO1133 | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 38018572 | 05 | TN |   | MEDICAID |