Provider Demographics
NPI:1083767883
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:STEWART COUNTY COMMUNITY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-650-7000
Mailing Address - Street 1:1021 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:TN
Mailing Address - Zip Code:37058-3302
Mailing Address - Country:US
Mailing Address - Phone:931-232-5329
Mailing Address - Fax:931-232-7247
Practice Address - Street 1:1021 SPRING ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:TN
Practice Address - Zip Code:37058-3302
Practice Address - Country:US
Practice Address - Phone:931-232-5329
Practice Address - Fax:931-232-7247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN251K00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4448019Medicaid
TN4448019Medicaid