Provider Demographics
NPI: | 1831133610 |
---|---|
Name: | PATY, JOHN G JR (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JOHN |
Middle Name: | G |
Last Name: | PATY |
Suffix: | JR |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1035 EXECUTIVE DRIVE |
Mailing Address - Street 2: | |
Mailing Address - City: | HIXSON |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37343-7908 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 423-826-0800 |
Mailing Address - Fax: | 423-826-0810 |
Practice Address - Street 1: | 1035 EXECUTIVE DRIVE |
Practice Address - Street 2: | |
Practice Address - City: | HIXSON |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37343-7908 |
Practice Address - Country: | US |
Practice Address - Phone: | 423-826-0800 |
Practice Address - Fax: | 423-826-0810 |
Is Sole Proprietor?: | Not Answered |
Enumeration Date: | 2006-06-15 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TN | 5955 | 207RR0500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TN | 62032 | Other | BLUE CROSS |
TN | 2008308 | Other | BLUE CROSS GROUP ID |
TN | 2008308 | Other | BLUE CROSS GROUP ID |
TN | D32066 | Medicare UPIN | |
TN | 3171164 | Medicare ID - Type Unspecified | MEDICARE |