MEDICARE: THERON L HUTTON MD

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	207Q00000X	Family Medicine Physician	036114648	IL
2	207Q00000X	Family Medicine Physician	49541	TN

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
2	4360245	OTHER		BCBST

General Provider Information

NPI Number	:	1922026806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERON L HUTTON MD

Provider Business Mailing Address
First Line	:	854 W JAMES CAMPBELL BLVD
Second Line	:	SUITE 303
City	:	COLUMBIA
State	:	TN
Zip	:	38401-4659
Country	:	US
Telephone Number	:	931-364-5090
Fax Number	:	931-364-5091

Provider Business Practice Location Address
First Line	:	4696 NASHVILLE HWY
Second Line	:
City	:	CHAPEL HILL
State	:	TN
Zip	:	37034-2110
Country	:	US
Telephone Number	:	931-364-5090
Fax Number	:	931-364-5091

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

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	01/15/2014

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