Healthcare Provider Details

I. General information

NPI: 1376083907
Provider Name (Legal Business Name): CARESTAR HEALTH ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6106 SHALLOWFORD RD STE 108
CHATTANOOGA TN
37421-2280
US

IV. Provider business mailing address

6106 SHALLOWFORD RD STE 108
CHATTANOOGA TN
37421-2280
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 Number35052
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number35052
License Number StateTN

VIII. Authorized Official

Name: DR. PHILIP A. BANNOR
Title or Position: PHYSICIAN
Credential: MD
Phone: 423-760-8700