Healthcare Provider Details

I. General information

NPI: 1134833445
Provider Name (Legal Business Name): BENJAMIN MICHAEL CHALSTROM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 TANNER WAY STE 220
HARRIMAN TN
37748-8332
US

IV. Provider business mailing address

1855 TANNER WAY STE 220
HARRIMAN TN
37748-8332
US

V. Phone/Fax

Practice location:
  • Phone: 865-882-2442
  • Fax: 865-374-2123
Mailing address:
  • Phone: 865-882-2442
  • Fax: 865-374-2123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5396
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: