Provider Demographics
NPI:1003823097
Name:CLARKSVILLE HEALTH SYSTEM GP
Entity Type:Organization
Organization Name:CLARKSVILLE HEALTH SYSTEM GP
Other - Org Name:GATEWAY HEALTH SYSTEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:HURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-473-3993
Mailing Address - Street 1:PO BOX 403765
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-3765
Mailing Address - Country:US
Mailing Address - Phone:931-552-6622
Mailing Address - Fax:931-551-1027
Practice Address - Street 1:1771 MADISON ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4990
Practice Address - Country:US
Practice Address - Phone:931-552-6622
Practice Address - Fax:931-551-1027
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLARKSVILLE HEALTH SYSTEM GP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-02
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1003823097Medicaid
3736508Medicare PIN
TN1003823097Medicaid