Provider Demographics
NPI:1790981066
Name:GIBSON COUNTY PODIATRY LLC
Entity Type:Organization
Organization Name:GIBSON COUNTY PODIATRY LLC
Other - Org Name:GIBSON COUNTY PODIATRY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:731-855-1040
Mailing Address - Street 1:91 MILAN HWY STE A
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358-6047
Mailing Address - Country:US
Mailing Address - Phone:731-855-1040
Mailing Address - Fax:731-855-3927
Practice Address - Street 1:91 MILAN HWY STE A
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-6047
Practice Address - Country:US
Practice Address - Phone:731-855-1040
Practice Address - Fax:731-855-3927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1790981066OtherNPI
TN103G704193Medicare PIN