Provider Demographics
NPI:1437200474
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:DEKALB COUNTY HEALTH DEPARTMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:HEALTH OFFICER / MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRISHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-520-4203
Mailing Address - Street 1:1100 ENGLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0924
Mailing Address - Country:US
Mailing Address - Phone:931-520-4201
Mailing Address - Fax:931-520-3871
Practice Address - Street 1:254 TIGER DR
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37166-6812
Practice Address - Country:US
Practice Address - Phone:615-597-7599
Practice Address - Fax:615-597-1349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN251K00000X, 251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN444-7863Medicaid
TN444-7863Medicaid
TNA99051Medicare UPIN
TN3159466Medicare PIN
TN3159466Medicare PIN