Provider Demographics
NPI:1780975540
Name:PERSONAL MEDICINE LLC
Entity type:Organization
Organization Name:PERSONAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BRENDLE
Authorized Official - Last Name:STANDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-531-4265
Mailing Address - Street 1:6838 BUCK TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:TN
Mailing Address - Zip Code:37341-4912
Mailing Address - Country:US
Mailing Address - Phone:423-531-4265
Mailing Address - Fax:423-531-4267
Practice Address - Street 1:207 SPEARS AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405
Practice Address - Country:US
Practice Address - Phone:423-531-4265
Practice Address - Fax:423-531-4267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-28
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1523731Medicaid