Provider Demographics
NPI:1861431652
Name:CLARKSVILLE HEALTH SYSTEM GP
Entity type:Organization
Organization Name:CLARKSVILLE HEALTH SYSTEM GP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OFFICE SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7000
Mailing Address - Street 1:PO BOX 403765
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-3765
Mailing Address - Country:US
Mailing Address - Phone:931-552-6622
Mailing Address - Fax:931-551-1027
Practice Address - Street 1:1760 MADISON ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4913
Practice Address - Country:US
Practice Address - Phone:931-552-6622
Practice Address - Fax:931-551-1027
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLARKSVILLE HEALTH SYSTEM GP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-06
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000623332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454419Medicaid
TN5670590001Medicare NSC