Provider Demographics
NPI:1265554091
Name:MID-STATE GASTROENTEROLOGY, PLLC
Entity type:Organization
Organization Name:MID-STATE GASTROENTEROLOGY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSALIND
Authorized Official - Middle Name:BROOK
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:615-896-6996
Mailing Address - Street 1:PO BOX 11209
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-0025
Mailing Address - Country:US
Mailing Address - Phone:615-896-6996
Mailing Address - Fax:615-896-6985
Practice Address - Street 1:517 HIGHLAND TER
Practice Address - Street 2:STE B
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-2476
Practice Address - Country:US
Practice Address - Phone:615-896-6996
Practice Address - Fax:615-896-6985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000026198174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00269512OtherRAILROAD MEDICARE
TN3730229Medicaid
TNP00269512OtherRAILROAD MEDICARE