Basic Information
| Provider Information | |||||||||
| NPI: | 1063407856 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDSTATE HEALTH ASSOCIATES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 MURPHY AVE | ||||||||
| Address2: | SUITE # 220 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153290494 | ||||||||
| FaxNumber: | 6155150205 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 MURPHY AVE | ||||||||
| Address2: | SUITE # 220 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153290494 | ||||||||
| FaxNumber: | 6155150205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2005 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | ADEWUMI | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6153290494 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 3725544 | 05 | TN | MEDICAID |