Basic Information
| Provider Information | |||||||||
| NPI: | 1891861274 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRABENSTEIN FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1822 MEMORIAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315528010 | ||||||||
| FaxNumber: | 9315513118 | ||||||||
| Practice Location | |||||||||
| Address1: | 1822 MEMORIAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315528010 | ||||||||
| FaxNumber: | 9315513118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | GRABENSTEIN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9315528010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3728817 | 05 | TN | MEDICAID | 4102303 | 01 | TN | BLUE CROSS | OTHER | 4102307 | 01 | TN | BLUE CROSS GROUP | OTHER |