Provider Demographics
NPI:1306036769
Name:HENDERSONVILLE OBGYN LLC
Entity Type:Organization
Organization Name:HENDERSONVILLE OBGYN LLC
Other - Org Name:BLUEGRASS OBSTETRICS AND GYNECOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7604
Mailing Address - Street 1:353 NEW SHACKLE ISLAND RD
Mailing Address - Street 2:SUITE 341-C
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2379
Mailing Address - Country:US
Mailing Address - Phone:615-826-1716
Mailing Address - Fax:615-826-4841
Practice Address - Street 1:353 NEW SHACKLE ISLAND RD
Practice Address - Street 2:SUITE 341-C
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2379
Practice Address - Country:US
Practice Address - Phone:615-826-1716
Practice Address - Fax:615-826-4841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3723252Medicaid
TN3723252Medicaid