Provider Demographics
NPI:1346530284
Name:FAIRBROTHER, SAMUEL WALTON
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WALTON
Last Name:FAIRBROTHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 25TH AVE N STE 1204
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1620
Mailing Address - Country:US
Mailing Address - Phone:615-312-0600
Mailing Address - Fax:615-320-3259
Practice Address - Street 1:210 25TH AVE N STE 1204
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1620
Practice Address - Country:US
Practice Address - Phone:615-312-0600
Practice Address - Fax:615-320-3259
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN569412085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ036873Medicaid