Provider Demographics
NPI:1417237728
Name:SOUTHERN SPORTS MEDICINE PORTLAND
Entity Type:Organization
Organization Name:SOUTHERN SPORTS MEDICINE PORTLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:GAUTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-452-3320
Mailing Address - Street 1:570 HARTSVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-2450
Mailing Address - Country:US
Mailing Address - Phone:615-452-3320
Mailing Address - Fax:615-452-2668
Practice Address - Street 1:121 VILLAGE DR
Practice Address - Street 2:STE 102 & 103
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1418
Practice Address - Country:US
Practice Address - Phone:615-325-1180
Practice Address - Fax:615-452-2668
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN SPORTS MEDICINE INSTITUTE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000026910174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty