Provider Demographics
NPI:1356561856
Name:NORTHCREST PHYSICIAN SERVICES INC
Entity type:Organization
Organization Name:NORTHCREST PHYSICIAN SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:JERLYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-382-5710
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-0969
Mailing Address - Country:US
Mailing Address - Phone:615-382-5710
Mailing Address - Fax:615-382-5776
Practice Address - Street 1:417 NORTHCREST DR
Practice Address - Street 2:430 NORTHCREST DR
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-3973
Practice Address - Country:US
Practice Address - Phone:615-382-5710
Practice Address - Fax:615-382-5776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31309207R00000X
TN37667207X00000X
TN31565207X00000X
TN24985207Q00000X
TNMD6465207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3709970OtherMEDICARE GROUP NUMBER
TN3371051OtherMEDICARE GROUP NUMBER
TN3709979OtherMEDICARE GROUP NUMBER
TN=========OtherTAX IDENTIFICATION EIN
TN3709979Medicare PIN
TN3709970Medicare PIN
TN3371051OtherMEDICARE GROUP NUMBER
TN3884852Medicare PIN
TN3709970OtherMEDICARE GROUP NUMBER
TN=========OtherTAX IDENTIFICATION EIN
TN3848225Medicare PIN
TN3081844Medicare PIN