Provider Demographics
NPI:1073634085
Name:MIDDLE TENNESSEE AND ADOLESCENT MEDICINE P.C.
Entity Type:Organization
Organization Name:MIDDLE TENNESSEE AND ADOLESCENT MEDICINE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:HARMON
Authorized Official - Last Name:CLAYCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-449-5611
Mailing Address - Street 1:100 PHYSICIANS WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37090-8102
Mailing Address - Country:US
Mailing Address - Phone:615-449-5611
Mailing Address - Fax:615-443-0571
Practice Address - Street 1:100 PHYSICIANS WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-8102
Practice Address - Country:US
Practice Address - Phone:615-449-5611
Practice Address - Fax:615-443-0571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD023656261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNF33153Medicare UPIN