Provider Demographics
NPI:1700097417
Name:CROSSVILLE ORTHOPAEDICS & SPORTS MEDICINE PLLC
Entity Type:Organization
Organization Name:CROSSVILLE ORTHOPAEDICS & SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:TYSON
Authorized Official - Last Name:GARLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-484-3401
Mailing Address - Street 1:35 TAYLOR AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4526
Mailing Address - Country:US
Mailing Address - Phone:931-484-3401
Mailing Address - Fax:931-484-3405
Practice Address - Street 1:35 TAYLOR AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4526
Practice Address - Country:US
Practice Address - Phone:931-484-3401
Practice Address - Fax:931-484-3405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2008-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD37289174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3717972Medicaid
TN4062795OtherBLUE CROSS
TNP00047359OtherMEDICARE RAILROAD
TNE73443Medicare UPIN
TN3717972Medicare ID - Type Unspecified
TN5257570001Medicare NSC