Provider Demographics
NPI:1396767968
Name:COOKEVILLE CARDIAC ANESTHESIA, P.C.
Entity type:Organization
Organization Name:COOKEVILLE CARDIAC ANESTHESIA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLEMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-526-8513
Mailing Address - Street 1:DEPT 888152
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37995-8152
Mailing Address - Country:US
Mailing Address - Phone:931-526-8513
Mailing Address - Fax:931-526-5422
Practice Address - Street 1:682 CANTER LN
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4523
Practice Address - Country:US
Practice Address - Phone:931-526-8513
Practice Address - Fax:931-526-5422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3732052Medicaid
TN3732052Medicaid
TN3732052Medicare PIN
=========OtherTAX ID #