Provider Demographics
NPI:1700983236
Name:CANNON COUNTY HOSPITAL, LLC
Entity Type:Organization
Organization Name:CANNON COUNTY HOSPITAL, LLC
Other - Org Name:DEKALB COMMUNITY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:Y
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-563-7201
Mailing Address - Street 1:520 W MAIN ST
Mailing Address - Street 2:P.O. 640
Mailing Address - City:SMITHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37166-1138
Mailing Address - Country:US
Mailing Address - Phone:615-215-5300
Mailing Address - Fax:615-215-5600
Practice Address - Street 1:520 W MAIN ST
Practice Address - Street 2:P.O. 640
Practice Address - City:SMITHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37166-1138
Practice Address - Country:US
Practice Address - Phone:615-215-5300
Practice Address - Fax:615-215-5600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000138282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN440148Medicare Oscar/Certification