Basic Information
| Provider Information | |||||||||
| NPI: | 1750389979 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STALCUP | ||||||||
| FirstName: | CLAY | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 440014 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372440014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706199 | ||||||||
| FaxNumber: | 8656706198 | ||||||||
| Practice Location | |||||||||
| Address1: | 11606 CHAPMAN HWY | ||||||||
| Address2: | STE 2 | ||||||||
| City: | SEYMOUR | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378655270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656096980 | ||||||||
| FaxNumber: | 8656096982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 10/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD38159 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 33279402 | 05 | TN | MEDICAID |