Healthcare Provider Details

I. General information

NPI: 1215330592
Provider Name (Legal Business Name): THOMAS P. BOVINE MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7794 RHEA COUNTY HWY STE 101
DAYTON TN
37321-5981
US

IV. Provider business mailing address

7794 RHEA COUNTY HWY STE 101
DAYTON TN
37321-5981
US

V. Phone/Fax

Practice location:
  • Phone: 423-775-3363
  • Fax: 423-775-3366
Mailing address:
  • Phone: 423-775-3363
  • Fax: 423-775-3366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14692
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13493
License Number StateTN

VIII. Authorized Official

Name: CARRIE J NORTON
Title or Position: OFFICE COORDINATOR
Credential:
Phone: 423-775-3363