Provider Demographics
NPI:1942252648
Name:TERRACE PEDIATRIC GROUP LLC
Entity Type:Organization
Organization Name:TERRACE PEDIATRIC GROUP LLC
Other - Org Name:TERRACE PEDIATRIC GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-327-9371
Mailing Address - Street 1:342 21ST AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1848
Mailing Address - Country:US
Mailing Address - Phone:615-327-9371
Mailing Address - Fax:615-329-6652
Practice Address - Street 1:342 21ST AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1848
Practice Address - Country:US
Practice Address - Phone:615-327-9371
Practice Address - Fax:615-329-6652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6169208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3706486Medicaid
TN678067OtherAETNA
TN3706486Medicaid