MEDICARE: DR. LARRY W CARRUTH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MD009363	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	621582944	OTHER	TN	TAX ID -COMMERCIAL INS
2	000050023	OTHER	TN	BCBS OF TN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306835483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY W CARRUTH M.D.

Provider Business Mailing Address
First Line	:	96 PHYSICIANS DR
Second Line	:	96 PHYSICIANS DRIVE
City	:	JACKSON
State	:	TN
Zip	:	38305-2070
Country	:	US
Telephone Number	:	731-664-8771
Fax Number	:	731-660-7050

Provider Business Practice Location Address
First Line	:	96 PHYSICIANS DR
Second Line	:	96 PHYSICIANS DRIVE
City	:	JACKSON
State	:	TN
Zip	:	38305-2070
Country	:	US
Telephone Number	:	731-664-8771
Fax Number	:	731-660-7050

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	04/06/2015

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