Provider Demographics
NPI:1831229475
Name:CORDOVA MEDICAL & COSMEDIC SOLUTIONS, PC
Entity type:Organization
Organization Name:CORDOVA MEDICAL & COSMEDIC SOLUTIONS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:J
Authorized Official - Last Name:CRUPIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-507-4400
Mailing Address - Street 1:PO BOX 4438
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38088-4438
Mailing Address - Country:US
Mailing Address - Phone:901-507-4400
Mailing Address - Fax:901-756-5836
Practice Address - Street 1:1025 CORDOVA STATION AVE
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-6318
Practice Address - Country:US
Practice Address - Phone:901-507-4400
Practice Address - Fax:901-756-5836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD15815261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3144579OtherBLUE CROSS BLUE SHIELD
TNA98067Medicare UPIN
TN3829438Medicare ID - Type Unspecified