Provider Demographics
NPI:1902132509
Name:MOSE AND GARRISON SISKIN MEMORIAL FOUNDATION, INC.
Entity Type:Organization
Organization Name:MOSE AND GARRISON SISKIN MEMORIAL FOUNDATION, INC.
Other - Org Name:SISKIN CENTER FOR DEVELOPMENTAL PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR HEALTHCARE ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER-WILKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-490-7727
Mailing Address - Street 1:1101 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-5017
Mailing Address - Country:US
Mailing Address - Phone:423-490-7710
Mailing Address - Fax:423-490-7750
Practice Address - Street 1:1101 CARTER ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-5017
Practice Address - Country:US
Practice Address - Phone:423-490-7710
Practice Address - Fax:423-490-7750
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOSE AND GARRISON SISKIN MEMORIAL FOUNDATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-02
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003136978AMedicaid
TN1527698Medicaid