Provider Demographics
NPI:1679834998
Name:UAP CHATTANOOGA PAIN, LLC
Entity Type:Organization
Organization Name:UAP CHATTANOOGA PAIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:423-933-8596
Mailing Address - Street 1:1016 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3995
Mailing Address - Country:US
Mailing Address - Phone:615-376-7550
Mailing Address - Fax:615-329-6290
Practice Address - Street 1:1016 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-3995
Practice Address - Country:US
Practice Address - Phone:423-648-4525
Practice Address - Fax:423-648-4626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-04
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G704781Medicare PIN