Provider Demographics
NPI:1942255575
Name:BADRU, ALEXANDER OLATUNDE (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:OLATUNDE
Last Name:BADRU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BADRU
Other - Middle Name:O
Other - Last Name:TUNDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:521 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3460
Mailing Address - Country:US
Mailing Address - Phone:615-547-6200
Mailing Address - Fax:615-547-6202
Practice Address - Street 1:521 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3460
Practice Address - Country:US
Practice Address - Phone:615-547-6200
Practice Address - Fax:615-547-6202
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41138207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510652Medicaid
743222061OtherINDIVIDUAL TAX ID
300400371OtherGROUP TAX ID
TN38146801Medicare PIN
TNI63192Medicare UPIN
38146803Medicare UPIN
300400371OtherGROUP TAX ID