Provider Demographics
NPI:1255469235
Name:CLEVELAND HEAD & NECK CLINIC
Entity Type:Organization
Organization Name:CLEVELAND HEAD & NECK CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-472-6581
Mailing Address - Street 1:2414 CHAMBLISS AVE NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-3879
Mailing Address - Country:US
Mailing Address - Phone:423-472-6581
Mailing Address - Fax:423-472-2425
Practice Address - Street 1:2414 CHAMBLISS AVE NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3879
Practice Address - Country:US
Practice Address - Phone:423-472-6581
Practice Address - Fax:423-472-2425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3386305Medicaid
TN0024126OtherBCBS
TN3386305Medicaid