Provider Demographics
NPI:1780977207
Name:PEGRAM, KATIE GREENE (MD)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:GREENE
Last Name:PEGRAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:KATIE
Other - Middle Name:MARIE
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3799
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-3799
Mailing Address - Country:US
Mailing Address - Phone:931-245-7000
Mailing Address - Fax:
Practice Address - Street 1:490 DUNLOP LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5007
Practice Address - Country:US
Practice Address - Phone:931-245-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN51676208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ028432Medicaid