Provider Demographics
NPI:1679821623
Name:CHOTA COMMUNITY HEALTH SERVICES
Entity Type:Organization
Organization Name:CHOTA COMMUNITY HEALTH SERVICES
Other - Org Name:MADISONVILLE INTERMEDIATE SCHOOL BASED CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:PUSPA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-442-2622
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37354-0278
Mailing Address - Country:US
Mailing Address - Phone:423-442-2622
Mailing Address - Fax:
Practice Address - Street 1:1000 GREEN RD
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37354-7062
Practice Address - Country:US
Practice Address - Phone:423-442-2454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHOTA COMMUNITY HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-23
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty