Provider Demographics
NPI:1952307415
Name:GANNAWAY, RICHARD P (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:P
Last Name:GANNAWAY
Suffix:
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 1:141 CHESAPEAKE LANE # 300
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040
Mailing Address - Country:US
Mailing Address - Phone:931-552-6830
Mailing Address - Fax:931-552-2847
Practice Address - Street 1:141 CHESAPEAKE LANE # 300
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040
Practice Address - Country:US
Practice Address - Phone:931-552-6830
Practice Address - Fax:931-552-2847
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000019272174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3375635Medicare ID - Type Unspecified
TNE76161Medicare UPIN