Provider Demographics
NPI:1063473346
Name:FLY, WILLIAM RANDOLPH (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RANDOLPH
Last Name:FLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:120 HOSPITAL DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-5287
Mailing Address - Country:US
Mailing Address - Phone:865-475-4484
Mailing Address - Fax:865-475-1124
Practice Address - Street 1:120 HOSPITAL DR
Practice Address - Street 2:SUITE 250
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-5287
Practice Address - Country:US
Practice Address - Phone:865-475-4484
Practice Address - Fax:865-475-1124
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15794207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01315239OtherRAILROAD MEDICARE
TNQ001842Medicaid
2577295OtherCIGNA
GA200046272OtherRAILROAD MEDICARE
TN6004897OtherBLUECROSS BLUESHIELD
TN7962437OtherAETNA
2577295OtherCIGNA
TN103I202356Medicare PIN
GA200046272OtherRAILROAD MEDICARE
E93894Medicare UPIN
TNQ001842Medicaid
TN6004897OtherBLUECROSS BLUESHIELD