Provider Demographics
NPI:1780618942
Name:TENNESSEE PHLEBOLOGY PC
Entity type:Organization
Organization Name:TENNESSEE PHLEBOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP REVENUE
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AMORUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-593-8460
Mailing Address - Street 1:PO BOX 1602
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-1602
Mailing Address - Country:US
Mailing Address - Phone:847-593-8460
Mailing Address - Fax:
Practice Address - Street 1:9020 OVERLOOK BLVD STE 150
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-2727
Practice Address - Country:US
Practice Address - Phone:615-401-7162
Practice Address - Fax:615-401-7163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2023-05-04
Deactivation Date:2021-05-05
Deactivation Code:
Reactivation Date:2021-06-22
Provider Licenses
StateLicense IDTaxonomies
TN2085R0204X, 208600000X, 2086S0129X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3733226Medicare PIN