Provider Demographics
NPI:1811121924
Name:HARE, JOSHUA LIDELLE (DO)
Entity type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:LIDELLE
Last Name:HARE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 BUSINESS PARK DR NE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-6503
Mailing Address - Country:US
Mailing Address - Phone:423-605-8075
Mailing Address - Fax:423-472-0454
Practice Address - Street 1:6141 SHALLOWFORD RD STE 100
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1663
Practice Address - Country:US
Practice Address - Phone:423-498-2000
Practice Address - Fax:423-498-2001
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA071791207LP2900X, 207RA0401X
TN2663207RA0401X, 2083A0300X
GA717912083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA988220OtherWELLCARE
GAP01363024OtherRR MEDICARE
TNQ02347Medicaid
GA003147609AMedicaid
GA02045387OtherAMERIGROUP