Provider Demographics
NPI: | 1306835483 |
---|---|
Name: | CARRUTH, LARRY W (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | LARRY |
Middle Name: | W |
Last Name: | CARRUTH |
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: | 96 PHYSICIANS DR |
Mailing Address - Street 2: | 96 PHYSICIANS DRIVE |
Mailing Address - City: | JACKSON |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 38305-2070 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 731-664-8771 |
Mailing Address - Fax: | 731-660-7050 |
Practice Address - Street 1: | 96 PHYSICIANS DR |
Practice Address - Street 2: | 96 PHYSICIANS DRIVE |
Practice Address - City: | JACKSON |
Practice Address - State: | TN |
Practice Address - Zip Code: | 38305-2070 |
Practice Address - Country: | US |
Practice Address - Phone: | 731-664-8771 |
Practice Address - Fax: | 731-660-7050 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-10-20 |
Last Update Date: | 2015-04-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TN | MD009363 | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TN | 621582944 | Other | TAX ID -COMMERCIAL INS |
TN | 000050023 | Other | BCBS OF TN |
TN | 3170825 | Medicaid | |
TN | 000050023 | Other | BCBS OF TN |
TN | 3170825 | Medicare ID - Type Unspecified | MEDICARE |