Basic Information
| Provider Information | |||||||||
| NPI: | 1982929279 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC CONSULTANTS WEST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 440215 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372440215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706199 | ||||||||
| FaxNumber: | 8656706188 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 HUXLEY RD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656913335 | ||||||||
| FaxNumber: | 8656913310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2010 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | DEROSSETT | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8656913335 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1518261 | 05 | TN | MEDICAID |