Provider Demographics
NPI:1922057181
Name:MID-TENNESSEE BONE & JOINT
Entity Type:Organization
Organization Name:MID-TENNESSEE BONE & JOINT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-381-2663
Mailing Address - Street 1:1050 N JAMES CAMPBELL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-2754
Mailing Address - Country:US
Mailing Address - Phone:931-381-2663
Mailing Address - Fax:931-840-0234
Practice Address - Street 1:1050 N JAMES CAMPBELL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-2754
Practice Address - Country:US
Practice Address - Phone:931-381-2663
Practice Address - Fax:931-840-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3376038Medicare ID - Type Unspecified
TN0419280002Medicare NSC