Healthcare Provider Details

I. General information

NPI: 1043667686
Provider Name (Legal Business Name): CARESTAR MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6106 SHALLOWFORD RD SUITE 108
CHATTANOOGA TN
37421-2239
US

IV. Provider business mailing address

6106 SHALLOWFORD RD SUITE 108
CHATTANOOGA TN
37421-2239
US

V. Phone/Fax

Practice location:
  • Phone: 423-760-8700
  • Fax: 423-760-8703
Mailing address:
  • Phone: 423-760-8700
  • Fax: 423-760-8703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PHILLIP BANNOR
Title or Position: OWNER
Credential: M.D.
Phone: 423-760-8700