Provider Demographics
NPI:1619056462
Name:STEPHEN V DRESKIN MD PC
Entity Type:Organization
Organization Name:STEPHEN V DRESKIN MD PC
Other - Org Name:TENNESSEE VALLEY PAIN MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-664-4635
Mailing Address - Street 1:6130 SHALLOWFORD RD
Mailing Address - Street 2:STE 101
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7222
Mailing Address - Country:US
Mailing Address - Phone:423-664-4635
Mailing Address - Fax:423-664-4640
Practice Address - Street 1:6130 SHALLOWFORD RD
Practice Address - Street 2:STE 101
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-7222
Practice Address - Country:US
Practice Address - Phone:423-664-4635
Practice Address - Fax:423-664-4640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26298174400000X
TN26240174400000X
208VP0000X, 291U00000X
TN846363A00000X
TN11764363L00000X
TNAPN8476363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3882406Medicaid
TN3642504Medicaid
TN3671003Medicaid
TN3088189Medicaid
TN3088189Medicare ID - Type Unspecified
TNG00854Medicare UPIN
TNF95585Medicare UPIN
TN3642504Medicare ID - Type Unspecified
TN3642504Medicaid
P61645Medicare UPIN
TN3671003Medicare ID - Type Unspecified
TN3088189Medicaid
TN3882406Medicaid