Basic Information
| Provider Information | |||||||||
| NPI: | 1396780565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANOS | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JUDSON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 633819 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652923000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 NORTHCREST DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371723927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153842411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 11/12/2007 | ||||||||
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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 | 207P00000X | 0000010607 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64106206 | 05 | KY | MEDICAID | 4101901 | 01 | TN | BLUECROSS | OTHER | 3173274 | 05 | TN | MEDICAID | P00287014 | 01 | TN | RAILROAD MEDICARE | OTHER |