Provider Demographics
NPI:1346535853
Name:MIDDLE TENNESSEE OCCUPATIONAL MEDICINE
Entity Type:Organization
Organization Name:MIDDLE TENNESSEE OCCUPATIONAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-443-1744
Mailing Address - Street 1:936 MURFREESBORO RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37090-5350
Mailing Address - Country:US
Mailing Address - Phone:615-443-1744
Mailing Address - Fax:615-443-1374
Practice Address - Street 1:936 MURFREESBORO RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-5350
Practice Address - Country:US
Practice Address - Phone:615-443-1744
Practice Address - Fax:615-443-1374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN02209173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN=========OtherTAX ID