Provider Demographics
NPI:1679771240
Name:OLD HICKORY EMERGENCY PHYSICIANS
Entity Type:Organization
Organization Name:OLD HICKORY EMERGENCY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVASNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-355-0808
Mailing Address - Street 1:PO BOX 13858
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-3858
Mailing Address - Country:US
Mailing Address - Phone:800-355-0808
Mailing Address - Fax:215-834-2862
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-5031
Practice Address - Country:US
Practice Address - Phone:615-865-0300
Practice Address - Fax:615-312-8317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3726452Medicaid
TN3726452Medicare ID - Type Unspecified