Provider Demographics
NPI:1942295589
Name:FAUST, LARRY M (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:M
Last Name:FAUST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:515 STONECREST PKWY
Mailing Address - Street 2:STE 210
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6826
Mailing Address - Country:US
Mailing Address - Phone:615-625-7112
Mailing Address - Fax:615-625-7028
Practice Address - Street 1:800 WEATHERLY DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8943
Practice Address - Country:US
Practice Address - Phone:931-648-1912
Practice Address - Fax:931-648-1277
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD08258208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440539Medicaid
B02960Medicare UPIN
TN5440539Medicaid