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
StateLicense IDTaxonomies
TNMD009363174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN621582944OtherTAX ID -COMMERCIAL INS
TN000050023OtherBCBS OF TN
TN3170825Medicaid
TN000050023OtherBCBS OF TN
TN3170825Medicare ID - Type UnspecifiedMEDICARE