Provider Demographics
NPI:1366581654
Name:CLEVELAND BACK & NECK CLINIC, PLLC
Entity type:Organization
Organization Name:CLEVELAND BACK & NECK CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:FREE
Authorized Official - Last Name:MCPHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:423-478-8989
Mailing Address - Street 1:PO BOX 3604
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37320-3604
Mailing Address - Country:US
Mailing Address - Phone:423-478-8989
Mailing Address - Fax:423-478-8992
Practice Address - Street 1:55 MOUSE CREEK RD NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4840
Practice Address - Country:US
Practice Address - Phone:423-479-8989
Practice Address - Fax:423-478-8992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN111N00000X, 363L00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4103176OtherBCBS
TN3676963OtherINDIVIDUAL MEDICAID # DR ANGELA
TNP00232343OtherRAILROAD MEDICARE
TN3730173Medicaid
TN3730173Medicaid
TN6659230001Medicare NSC
TN10350I5479Medicare PIN
TN3676963OtherINDIVIDUAL MEDICAID # DR ANGELA
TNU45811Medicare UPIN