Provider Demographics
NPI:1467716142
Name:PROVIDENCE OBSTETRICS AND GYNECOLOGY, PLLC
Entity Type:Organization
Organization Name:PROVIDENCE OBSTETRICS AND GYNECOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NINA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-984-4751
Mailing Address - Street 1:300 STONECREST BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-5688
Mailing Address - Country:US
Mailing Address - Phone:615-984-4751
Mailing Address - Fax:615-984-4752
Practice Address - Street 1:300 STONECREST BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-5688
Practice Address - Country:US
Practice Address - Phone:615-984-4751
Practice Address - Fax:615-984-4752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41688207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G709136Medicare PIN