Basic Information
| Provider Information | |||||||||
| NPI: | 1942480611 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDTRACK, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 610 | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370700610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153521212 | ||||||||
| FaxNumber: | 6153521215 | ||||||||
| Practice Location | |||||||||
| Address1: | 28 WHITE BRIDGE RD STE 108 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372051466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153521212 | ||||||||
| FaxNumber: | 6153521215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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| AuthorizedOfficialLastName: | SAVAGE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | ABNER | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6153521212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | 100002 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
ID Information
| ID | Type | State | Issuer | Description | 027765 | 01 | AANA CERTIFICATION NUMBER | OTHER |