Healthcare Provider Details

I. General information

NPI: 1518953165
Provider Name (Legal Business Name): PHILIP V DAUGHERTY II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 N HIGHLAND PARK AVE
CHATTANOOGA TN
37404
US

IV. Provider business mailing address

4976 ALPHA LN
HIXSON TN
37343-5470
US

V. Phone/Fax

Practice location:
  • Phone: 423-209-6070
  • Fax: 423-209-6071
Mailing address:
  • Phone: 423-308-0280
  • Fax: 423-308-0281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17556
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: