Healthcare Provider Details

I. General information

NPI: 1467133371
Provider Name (Legal Business Name): COOKEVILLE HOSPITALIST GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD
COOKEVILLE TN
38501-4294
US

IV. Provider business mailing address

5665 NEW NORTHSIDE DR STE 320
ATLANTA GA
30328-5834
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-2541
  • Fax:
Mailing address:
  • Phone: 770-874-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM LARSEN
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 770-874-5400