Provider Demographics
NPI:1679718662
Name:SR MEDICAL SERVICES, LLC
Entity Type:Organization
Organization Name:SR MEDICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-562-8339
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:CARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37714-0043
Mailing Address - Country:US
Mailing Address - Phone:423-562-8339
Mailing Address - Fax:423-562-8339
Practice Address - Street 1:138 HERRON LN
Practice Address - Street 2:
Practice Address - City:CARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37714-3258
Practice Address - Country:US
Practice Address - Phone:423-562-8339
Practice Address - Fax:423-562-8339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-05
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD42643207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3000372Medicare PIN
TN30003723Medicare PIN
E52296Medicare UPIN