Provider Demographics
NPI:1780709451
Name:GATEWAY MEDICAL ASSOCIATES, P.C.
Entity type:Organization
Organization Name:GATEWAY MEDICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPA
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:JUDD
Authorized Official - Suffix:III
Authorized Official - Credentials:CPA
Authorized Official - Phone:931-905-0520
Mailing Address - Street 1:PO BOX 3540
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-3540
Mailing Address - Country:US
Mailing Address - Phone:931-648-0202
Mailing Address - Fax:931-648-0252
Practice Address - Street 1:751 CHESAPEAKE LANE
Practice Address - Street 2:STE 101
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5263
Practice Address - Country:US
Practice Address - Phone:931-648-0202
Practice Address - Fax:931-648-0252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO1235207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3144330OtherBLUE CROSS & BLUE SHIELD
TN3305160Medicaid
TNG61607Medicare UPIN
TN3305160Medicaid