Provider Demographics
NPI:1679029763
Name:BAXTER, JOHNNY
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:BAXTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11661 BRADYVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:READYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37149-4517
Mailing Address - Country:US
Mailing Address - Phone:615-848-2700
Mailing Address - Fax:615-907-7200
Practice Address - Street 1:2230 SOUTHGATE BLVD STE B
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-5509
Practice Address - Country:US
Practice Address - Phone:615-848-2700
Practice Address - Fax:615-907-7200
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0547685343900000X, 344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No344600000XTransportation ServicesTaxi