Provider Demographics
NPI:1689971525
Name:SARAH MOON THELEN MD PLLC
Entity Type:Organization
Organization Name:SARAH MOON THELEN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:MOON
Authorized Official - Last Name:THELEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-227-4984
Mailing Address - Street 1:2330 THORNTON TAYLOR PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-3672
Mailing Address - Country:US
Mailing Address - Phone:931-227-4984
Mailing Address - Fax:931-227-4985
Practice Address - Street 1:305 COLLEGE ST W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-2911
Practice Address - Country:US
Practice Address - Phone:931-227-4984
Practice Address - Fax:931-227-4985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-11
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1522804Medicaid
TN103G700423Medicare PIN