Provider Demographics
NPI:1548575400
Name:AVE MARIA MEDICAL PLLC
Entity Type:Organization
Organization Name:AVE MARIA MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:U
Authorized Official - Last Name:EFOBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-443-2544
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37088-0570
Mailing Address - Country:US
Mailing Address - Phone:615-443-2544
Mailing Address - Fax:615-443-2548
Practice Address - Street 1:1411 W BADDOUR PKWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2513
Practice Address - Country:US
Practice Address - Phone:615-443-2544
Practice Address - Fax:615-443-2548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000040753207R00000X
TNMD00000405242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty