Healthcare Provider Details

I. General information

NPI: 1831658632
Provider Name (Legal Business Name): ETHAN ALEXANDER HYDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 CRESTVIEW PARK DR STE 207
DICKSON TN
37055-2856
US

IV. Provider business mailing address

3024 BUSINESS PARK CIR
GOODLETTSVILLE TN
37072-3132
US

V. Phone/Fax

Practice location:
  • Phone: 158-140-8856
  • Fax: 615-814-0056
Mailing address:
  • Phone: 615-239-2018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number926
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: