Healthcare Provider Details

I. General information

NPI: 1144330606
Provider Name (Legal Business Name): JACK P. BYRD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2414 CHAMBLISS AVE N.W.
CLEVELAND TN
37311
US

IV. Provider business mailing address

2414 CHAMBLISS AVE N.W.
CLEVELAND TN
37311
US

V. Phone/Fax

Practice location:
  • Phone: 423-472-6581
  • Fax: 423-472-2425
Mailing address:
  • Phone: 423-472-6581
  • Fax: 423-472-2425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMD14726
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: