Provider Demographics
NPI:1306831417
Name:TULLAHOMA ORTHOPAEDICS & SPORTS MEDICINE PLLC
Entity Type:Organization
Organization Name:TULLAHOMA ORTHOPAEDICS & SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:931-455-8676
Mailing Address - Street 1:1816 N WASHINGTON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2222
Mailing Address - Country:US
Mailing Address - Phone:931-455-8676
Mailing Address - Fax:931-455-9983
Practice Address - Street 1:1816 N WASHINGTON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2222
Practice Address - Country:US
Practice Address - Phone:931-455-8676
Practice Address - Fax:931-455-9983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10070483OtherAMERIGROUP
TN3713655Medicaid
166220000OtherUS DEPT OF LABOR WORKER COMP
TN3093519OtherBLUE CROSS
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TN3093519OtherBLUE CROSS