Provider Demographics
NPI:1407865785
Name:GETHSEMANE CARDIOVASCULAR CLINIC
Entity Type:Organization
Organization Name:GETHSEMANE CARDIOVASCULAR CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-494-1255
Mailing Address - Street 1:1602 WEST NORTHFIELD BOULEVARD
Mailing Address - Street 2:SUITE 511 & 512
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-6057
Mailing Address - Country:US
Mailing Address - Phone:615-494-1255
Mailing Address - Fax:615-494-1274
Practice Address - Street 1:1602 W NORTHFIELD BLVD
Practice Address - Street 2:SUITE 511 & 512
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-6057
Practice Address - Country:US
Practice Address - Phone:615-494-1255
Practice Address - Fax:615-896-0403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD38872207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNMD38872OtherMD LICENSE