Provider Demographics
NPI:1548223084
Name:THEERATHORN, PITCHAR (MD)
Entity Type:Individual
Prefix:DR
First Name:PITCHAR
Middle Name:
Last Name:THEERATHORN
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:PO BOX 3889
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3889
Mailing Address - Country:US
Mailing Address - Phone:423-794-2457
Mailing Address - Fax:423-283-9480
Practice Address - Street 1:301 MED TECH PKWY STE 240
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2641
Practice Address - Country:US
Practice Address - Phone:423-794-5520
Practice Address - Fax:423-282-6940
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26545207R00000X
TN35127208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3877775Medicaid
FL279422500Medicaid
SC562173631OtherTAX ID
FLAD055YMedicare PIN
TNH73357Medicare UPIN
SCH73357Medicare UPIN
TN3877775Medicaid