Healthcare Provider Details

I. General information

NPI: 1326764556
Provider Name (Legal Business Name): OCTAVE TN MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 STUART LN
BRENTWOOD TN
37027-5822
US

IV. Provider business mailing address

912 STUART LN
BRENTWOOD TN
37027-5822
US

V. Phone/Fax

Practice location:
  • Phone: 650-459-0942
  • Fax:
Mailing address:
  • Phone: 615-406-4994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL EDGEWORTH
Title or Position: SOLE MEMBER
Credential: MD
Phone: 615-406-4994