Healthcare Provider Details

I. General information

NPI: 1962597179
Provider Name (Legal Business Name): CHATTANOOGA HAMILTON COUNTY HOSPITAL AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 TENNESSEE AVE STE 124
CHATTANOOGA TN
37409-1260
US

IV. Provider business mailing address

975 E THIRD STREET
CHATTANOOGA TN
37403
US

V. Phone/Fax

Practice location:
  • Phone: 423-778-4780
  • Fax: 423-778-4833
Mailing address:
  • Phone: 423-778-4780
  • Fax: 423-778-4833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number0000000140
License Number StateTN

VIII. Authorized Official

Name: MIKE DALE SHAVER
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 423-240-8576