Provider Demographics
NPI:1518963255
Name:GANTTE, STEPHEN C (MD)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:C
Last Name:GANTTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HOSPITAL DR
Mailing Address - Street 2:STE 130
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-5279
Mailing Address - Country:US
Mailing Address - Phone:865-475-4742
Mailing Address - Fax:865-475-4742
Practice Address - Street 1:120 HOSPITAL DR
Practice Address - Street 2:STE 130
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-5279
Practice Address - Country:US
Practice Address - Phone:865-475-4742
Practice Address - Fax:865-475-4742
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34928207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3871928Medicaid
TNH56771Medicare UPIN
TN3871928Medicaid