Basic Information
| Provider Information | |||||||||
| NPI: | 1083767883 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF TENNESSEE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | STEWART COUNTY COMMUNITY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370583302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312325329 | ||||||||
| FaxNumber: | 9312327247 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370583302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312325329 | ||||||||
| FaxNumber: | 9312327247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HALEY | ||||||||
| AuthorizedOfficialFirstName: | ANNETTE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6156507000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | TN | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 251K00000X | TN | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 4448019 | 05 | TN | MEDICAID |