MEDICARE: DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES, STATE OF TN

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	251K00000X	Public Health or Welfare Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447618061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES, STATE OF TN

Provider Business Mailing Address
First Line	:	400 DEADERICK ST
Second Line	:	9TH FLOOR, CITIZEN PLAZA BUILDING
City	:	NASHVILLE
State	:	TN
Zip	:	37243-1403
Country	:	US
Telephone Number	:	615-532-6530
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 DEADERICK ST
Second Line	:	9TH FLOOR, CITIZEN PLAZA BUILDING
City	:	NASHVILLE
State	:	TN
Zip	:	37243-1403
Country	:	US
Telephone Number	:	615-532-6530
Fax Number	:

Authorized Official
Title or Position	:	DEPUTY COMMISSIONER, FINANCE & ADMI
Name	:	LANCE IVERSON
Credential	:
Telephone Number	:	615-253-6710

Provider Enumeration Date	:	02/10/2016
Last Update Date	:	02/10/2016

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