Basic Information
| Provider Information | |||||||||
| NPI: | 1679511471 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROCTOR | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634706 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652923000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 391 WALLACE RD | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372114851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157814000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| 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 | 20700 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3051994 | 01 | TN | BLUECROSS | OTHER | 3052176 | 05 | TN | MEDICAID | 3159791 | 01 | TN | BLUECROSS | OTHER | P00220920 | 01 | TN | RAILROAD MEDICARE | OTHER | 000000076048 | 01 | KY | BLUECROSS | OTHER | 00019934 | 05 | MS | MEDICAID | 3077695 | 01 | TN | BLUECROSS | OTHER | P00332581 | 01 | TN | RAILROAD MEDICARE | OTHER | 3052175 | 05 | TN | MEDICAID | 64798630 | 05 | KY | MEDICAID | 3052177 | 05 | TN | MEDICAID | 5M197 | 01 | AR | BLUECROSS | OTHER | P00248226 | 01 | TN | RAILROAD MEDICARE | OTHER |