Provider Demographics
NPI:1295130755
Name:CLARKSVILLE MONTGOMERY COUNTY SCHOOL SYSTEM
Entity type:Organization
Organization Name:CLARKSVILLE MONTGOMERY COUNTY SCHOOL SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SANFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-491-9571
Mailing Address - Street 1:350 PAGEANT LN
Mailing Address - Street 2:SUITE 307
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-8606
Mailing Address - Country:US
Mailing Address - Phone:931-906-2001
Mailing Address - Fax:931-648-5618
Practice Address - Street 1:350 PAGEANT LN
Practice Address - Street 2:SUITE 307
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-8606
Practice Address - Country:US
Practice Address - Phone:931-906-2001
Practice Address - Fax:931-648-5618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19272261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care