Provider Demographics
NPI:1508930249
Name:JEFFREY A LARSEN MD PLLC
Entity Type:Organization
Organization Name:JEFFREY A LARSEN MD PLLC
Other - Org Name:JEFFREY A LARSEN MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-223-9935
Mailing Address - Street 1:300 STONECREST BLVD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6818
Mailing Address - Country:US
Mailing Address - Phone:615-223-9935
Mailing Address - Fax:615-768-7871
Practice Address - Street 1:300 STONECREST BLVD
Practice Address - Street 2:SUITE 360
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6818
Practice Address - Country:US
Practice Address - Phone:615-223-9935
Practice Address - Fax:615-768-7871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30866208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3836764Medicaid
TN3836764Medicaid