Provider Demographics
NPI:1457998379
Name:SPECIALTY ORTHOPEDIC GROUP TENNESSEE
Entity Type:Organization
Organization Name:SPECIALTY ORTHOPEDIC GROUP TENNESSEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:CASSIDY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:615-237-5410
Mailing Address - Street 1:PO BOX 81
Mailing Address - Street 2:
Mailing Address - City:CASTALIAN SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37031-0081
Mailing Address - Country:US
Mailing Address - Phone:615-237-5431
Mailing Address - Fax:615-237-5411
Practice Address - Street 1:602 RED BOILING SPRINGS RD STE 106
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:TN
Practice Address - Zip Code:37083-1316
Practice Address - Country:US
Practice Address - Phone:615-237-5410
Practice Address - Fax:615-237-5411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-10
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ000435Medicaid