Provider Demographics
NPI:1104830801
Name:COX, FRED GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:GREGORY
Last Name:COX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH FULTON
Mailing Address - State:TN
Mailing Address - Zip Code:38257-2835
Mailing Address - Country:US
Mailing Address - Phone:731-479-2606
Mailing Address - Fax:731-479-2610
Practice Address - Street 1:1135 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SOUTH FULTON
Practice Address - State:TN
Practice Address - Zip Code:38257-2835
Practice Address - Country:US
Practice Address - Phone:731-479-2606
Practice Address - Fax:731-479-2610
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34657207R00000X
TN41561207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4045889Medicaid
KY6402855Medicaid
TN103I118585OtherMEDICARE B-TN
KY0933211Medicare PIN
KYG94710Medicare UPIN
KY0270812Medicare PIN