Basic Information
| Provider Information | |||||||||
| NPI: | 1932298700 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WYNDRIDGE HEALTH SYSTEMS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 456 WAYNE AVENUE | ||||||||
| Address2: | |||||||||
| City: | CROSSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314846129 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 456 WAYNE AVENUE | ||||||||
| Address2: | |||||||||
| City: | CROSSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314846129 | ||||||||
| FaxNumber: | 9314842685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 09/21/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COCHRAN | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9314846129 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 0000000312 | TN | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1454116 | 05 | TN | MEDICAID | 4011143 | 01 | BCBS | OTHER |