Provider Demographics
NPI:1700075421
Name:TENNESSEE SPORTS MEDICINE & ORTHOPAEDICS, PC
Entity Type:Organization
Organization Name:TENNESSEE SPORTS MEDICINE & ORTHOPAEDICS, PC
Other - Org Name:TENNESSEE SPORTS MEDICINE & ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:KAELIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:615-443-7700
Mailing Address - Street 1:1427 W BADDOUR PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2513
Mailing Address - Country:US
Mailing Address - Phone:615-443-7700
Mailing Address - Fax:615-443-7200
Practice Address - Street 1:1427 W BADDOUR PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2513
Practice Address - Country:US
Practice Address - Phone:615-443-7700
Practice Address - Fax:615-443-7200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3723654OtherMEDICARE GROUP NUMBER
TN3080388Medicaid