Provider Demographics
NPI:1396943841
Name:SCOTT O CAUDLE
Entity type:Organization
Organization Name:SCOTT O CAUDLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:OKRINA
Authorized Official - Last Name:CAUDLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-543-8619
Mailing Address - Street 1:1503 W ELK AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2883
Mailing Address - Country:US
Mailing Address - Phone:423-543-6660
Mailing Address - Fax:423-543-5133
Practice Address - Street 1:1503 W ELK AVE STE 3
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2883
Practice Address - Country:US
Practice Address - Phone:423-543-6660
Practice Address - Fax:423-543-5133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2021-08-31
Deactivation Date:2007-08-01
Deactivation Code:
Reactivation Date:2007-08-16
Provider Licenses
StateLicense IDTaxonomies
TNAPN12619363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380824Medicare PIN