Provider Demographics
NPI:1578590725
Name:TRUSSLER, JAY MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:MICHAEL
Last Name:TRUSSLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 INTERSTATE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-3191
Mailing Address - Country:US
Mailing Address - Phone:931-728-9000
Mailing Address - Fax:931-728-2726
Practice Address - Street 1:585 INTERSTATE DR
Practice Address - Street 2:SUITE B
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3191
Practice Address - Country:US
Practice Address - Phone:931-728-9000
Practice Address - Fax:931-728-2726
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN163207Q00000X
TN1634207Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN37-30274Medicaid
4105314OtherBC
4105314OtherBC
TN37-30274Medicaid