Provider Demographics
NPI:1619129285
Name:CLARKSVILLE GASTROENTEROLOGY PC
Entity Type:Organization
Organization Name:CLARKSVILLE GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MSN,RN
Authorized Official - Phone:931-552-0180
Mailing Address - Street 1:132 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5000
Mailing Address - Country:US
Mailing Address - Phone:931-552-0180
Mailing Address - Fax:931-572-0915
Practice Address - Street 1:132 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5000
Practice Address - Country:US
Practice Address - Phone:931-552-0180
Practice Address - Fax:931-572-0915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD17866207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA98993Medicare UPIN
TN3026037Medicare PIN