Provider Demographics
NPI:1346288966
Name:SOUTHWELL, CLYDE O (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:O
Last Name:SOUTHWELL
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 1:353 NEW SHACKLE ISLAND RD.
Mailing Address - Street 2:SUITE 140 C
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2379
Mailing Address - Country:US
Mailing Address - Phone:615-822-2214
Mailing Address - Fax:615-822-6519
Practice Address - Street 1:353 NEW SHACKLE ISLAND RD
Practice Address - Street 2:SUITE 140 C
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2379
Practice Address - Country:US
Practice Address - Phone:615-822-2214
Practice Address - Fax:615-822-6519
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43085174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01356OtherSC MEDICAID PROVIDER#
NC14014OtherBCBS PROVIDER#
NC0404464OtherEVERCARE
NC184386OtherMEDCOST PROVIDER#
NC5902491Medicaid
NCP00278679OtherPALMETTO GBA PROVIDER#
NCFH2967215OtherFCC PROVIDER#
NCP00278679OtherPALMETTO GBA PROVIDER#
NCH72472Medicare UPIN