Provider Demographics
NPI:1497019707
Name:MEDICAL ARTS PLAZA, P.C.
Entity Type:Organization
Organization Name:MEDICAL ARTS PLAZA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:DESJARLAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-942-1602
Mailing Address - Street 1:980 HIGHWAY 28
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JASPER
Mailing Address - State:TN
Mailing Address - Zip Code:37347-3695
Mailing Address - Country:US
Mailing Address - Phone:423-942-1602
Mailing Address - Fax:423-942-1265
Practice Address - Street 1:980 HIGHWAY 28
Practice Address - Street 2:SUITE 100
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3695
Practice Address - Country:US
Practice Address - Phone:423-942-1602
Practice Address - Fax:423-942-1265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-02
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25036207Q00000X
TN7170363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G700559Medicare PIN