Basic Information
| Provider Information | |||||||||
| NPI: | 1558675728 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TENNESSEE DEPARTMENT OF HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STEWART COUNTY COMMUNITY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 5TH AVE N | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372433400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157414733 | ||||||||
| FaxNumber: | 6155322286 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370583302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312325329 | ||||||||
| FaxNumber: | 9312327247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2010 | ||||||||
| LastUpdateDate: | 07/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | VAILLENCOURT | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9312325329 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | DO0000001638 | TN | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 1503176 | 05 | TN | MEDICAID |