Basic Information
| Provider Information | |||||||||
| NPI: | 1285659706 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VANDERBILT UNIVERSITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | VANDERBILT MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4163 VILLAGE AT VANDERBILT | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372328678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153223573 | ||||||||
| FaxNumber: | 6159366095 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 THE VANDERBILT CLINIC | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372325100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153223000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 12/13/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PINSON | ||||||||
| AuthorizedOfficialFirstName: | C. | ||||||||
| AuthorizedOfficialMiddleName: | WRIGHT | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6153223573 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.