Basic Information
| Provider Information | |||||||||
| NPI: | 1104812817 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEADRICK | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1949 GUNBARREL ROAD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234954349 | ||||||||
| FaxNumber: | 4234954934 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 GLENWOOD DRIVE, SUITE 105 | ||||||||
| Address2: | CHI MEMORIAL THORACIC ONCOLOGY ASSOCIATES | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234955864 | ||||||||
| FaxNumber: | 4234952065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 24097 | TN | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 3073584 | 05 | TN | MEDICAID |