Provider Demographics
NPI:1497915920
Name:PRODIGY TRUST COMPANY
Entity Type:Organization
Organization Name:PRODIGY TRUST COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:CARR
Authorized Official - Last Name:JESSUP
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:615-662-2800
Mailing Address - Street 1:7640 HIGHWAY 70 S
Mailing Address - Street 2:STE 204
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37221-1758
Mailing Address - Country:US
Mailing Address - Phone:615-662-2800
Mailing Address - Fax:615-662-0411
Practice Address - Street 1:7640 HIGHWAY 70 S
Practice Address - Street 2:STE 204
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37221-1758
Practice Address - Country:US
Practice Address - Phone:615-662-2800
Practice Address - Fax:615-662-0411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT000859152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0047504Medicaid
TN0792070001OtherMEDICARE DMERC PIN
TN3595039Medicare PIN
TN0792070001OtherMEDICARE DMERC PIN
TN0792070001Medicare NSC