Provider Demographics
NPI:1881885960
Name:DOUGLAS L. VANDERBILT, M.D. ,P.C.
Entity type:Organization
Organization Name:DOUGLAS L. VANDERBILT, M.D. ,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANDERBILT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-892-9200
Mailing Address - Street 1:PO BOX 23371
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37422-3371
Mailing Address - Country:US
Mailing Address - Phone:423-892-9208
Mailing Address - Fax:423-892-9212
Practice Address - Street 1:721 GLENWOOD DR
Practice Address - Street 2:MEMORIAL MEDICAL BLDG., WEST SUITE 470
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1106
Practice Address - Country:US
Practice Address - Phone:423-892-9208
Practice Address - Fax:423-892-9212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7995208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3384417Medicaid