Provider Demographics
NPI:1043903990
Name:HYDE PARK MEDICAL GROUP
Entity Type:Organization
Organization Name:HYDE PARK MEDICAL GROUP
Other - Org Name:HYDE PARK MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KHAISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-802-2723
Mailing Address - Street 1:PO BOX 23
Mailing Address - Street 2:
Mailing Address - City:GLADEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37071-0023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5380 HICKORY HOLLOW PKWY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3117
Practice Address - Country:US
Practice Address - Phone:615-412-8662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-29
Last Update Date:2023-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty