Provider Demographics
NPI:1700836202
Name:SOUTH CENTRAL HEART GROUP INC
Entity Type:Organization
Organization Name:SOUTH CENTRAL HEART GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-540-4255
Mailing Address - Street 1:854 W JAMES CAMPBELL BLVD
Mailing Address - Street 2:SUITE 303A
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4659
Mailing Address - Country:US
Mailing Address - Phone:931-540-4255
Mailing Address - Fax:931-490-4654
Practice Address - Street 1:1220 TROTWOOD AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-6433
Practice Address - Country:US
Practice Address - Phone:931-388-8622
Practice Address - Fax:931-388-8227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4074604OtherBLUECROSS BLUESHIELD
TN3379860Medicaid
TN3379860Medicare PIN
TN4074604OtherBLUECROSS BLUESHIELD