Healthcare Provider Details

I. General information

NPI: 1235297847
Provider Name (Legal Business Name): MOHAMMAD HASSAN KOUCHEKI M.D., P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 ELMO DR
CROSSVILLE TN
38555-4807
US

IV. Provider business mailing address

4196 HIGHWAY 62 412 STE A
HARDY AR
72542-8002
US

V. Phone/Fax

Practice location:
  • Phone: 931-484-5525
  • Fax: 931-456-8320
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number12315
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12315
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: