Provider Demographics
NPI:1740331792
Name:STATE OF TENNESSEE
Entity type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-520-4203
Mailing Address - Street 1:1100 ENGLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0924
Mailing Address - Country:US
Mailing Address - Phone:931-520-4203
Mailing Address - Fax:931-520-3871
Practice Address - Street 1:240 COLONIAL CIRCLE
Practice Address - Street 2:SUITE A
Practice Address - City:JAMESTOWN
Practice Address - State:TN
Practice Address - Zip Code:38556-3924
Practice Address - Country:US
Practice Address - Phone:931-879-9936
Practice Address - Fax:931-879-9938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN=========251K00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN444-7864Medicaid
TNA99051Medicare UPIN
TN44-1835Medicare PIN
TN3159466Medicare PIN
TN44-1835Medicare ID - Type Unspecified