Basic Information
| Provider Information | |||||||||
| NPI: | 1063738219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSSHARDT | ||||||||
| FirstName: | MARIBETH | ||||||||
| MiddleName: | HAMRICK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAMRICK | ||||||||
| OtherFirstName: | MARIBETH | ||||||||
| OtherMiddleName: | BANKS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 440100 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153290570 | ||||||||
| FaxNumber: | 6153290579 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 GLENWOOD DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374041130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236981844 | ||||||||
| FaxNumber: | 4236242226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2010 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 36717 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | 36717 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RH0002X | 48458 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q033728 | 05 | TN | MEDICAID |