Provider Demographics
NPI:1295879054
Name:MIDDLE TENNESSEE ORTHOPAEDICS, PC
Entity type:Organization
Organization Name:MIDDLE TENNESSEE ORTHOPAEDICS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:FOGOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-264-2600
Mailing Address - Street 1:353 NEW SHACKLE ISLAND RD
Mailing Address - Street 2:STE 226B
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2386
Mailing Address - Country:US
Mailing Address - Phone:615-264-2600
Mailing Address - Fax:615-590-0065
Practice Address - Street 1:353 NEW SHACKLE ISLAND RD
Practice Address - Street 2:STE 226B
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2386
Practice Address - Country:US
Practice Address - Phone:615-264-2600
Practice Address - Fax:615-590-0065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3716736Medicaid
G60425Medicare UPIN
TN3716736Medicaid
3957340002Medicare PIN