Provider Demographics
NPI:1912902099
Name:ESELGROTH, STEPHAN F (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:F
Last Name:ESELGROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 NORTHGATE MALL DR.
Mailing Address - Street 2:# 597
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343
Mailing Address - Country:US
Mailing Address - Phone:423-316-3614
Mailing Address - Fax:
Practice Address - Street 1:1013 EXECUTIVE DR STE 102
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-7913
Practice Address - Country:US
Practice Address - Phone:423-316-3614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36659208100000X
TNMD0000036511204C00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNMD0000036511OtherTN MEDICAL LICENSE NUMBER
TN4051823OtherBCBS ID NUMBER
KY36659OtherKY MEDICAL LICENSE NUMBER
TN250014020OtherRR MEDICARE
TN3879076Medicaid
TN3879076Medicaid
H72244Medicare UPIN