Basic Information
Provider Information | |||||||||
NPI: | 1790039188 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | JEREMIAH | ||||||||
MiddleName: | SHANE | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1949 GUNBARREL ROAD | ||||||||
Address2: | SUITE 230 | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 37421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234954349 | ||||||||
FaxNumber: | 4234954934 | ||||||||
Practice Location | |||||||||
Address1: | 605 GLENWOOD DRIVE, SUITE 105 | ||||||||
Address2: | CHI MEMORIAL THORACIC ONCOLOGY ASSOCIATES | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 37404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234955864 | ||||||||
FaxNumber: | 4234952065 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2012 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | APN0000016902 | TN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 16902 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
ID | Type | State | Issuer | Description | 16902 | 01 | TN | APN LICENSE | OTHER |