Provider Demographics
NPI:1609051895
Name:SHC MEDICAL PARTNERS OF TENNESSEE, LLC
Entity Type:Organization
Organization Name:SHC MEDICAL PARTNERS OF TENNESSEE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-558-2193
Mailing Address - Street 1:805 N WHITTINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-7101
Mailing Address - Country:US
Mailing Address - Phone:502-630-7532
Mailing Address - Fax:502-568-7121
Practice Address - Street 1:919 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN CITY
Practice Address - State:TN
Practice Address - Zip Code:37683-1042
Practice Address - Country:US
Practice Address - Phone:423-727-7800
Practice Address - Fax:423-727-2498
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHC MEDICAL PARTNERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-07
Last Update Date:2023-07-26
Deactivation Date:2019-03-06
Deactivation Code:
Reactivation Date:2019-03-15
Provider Licenses
StateLicense IDTaxonomies
TN0564617363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1506049OtherGROUP MEDICAID NUMBER
TN3289012Medicare PIN