Healthcare Provider Details

I. General information

NPI: 1306835483
Provider Name (Legal Business Name): LARRY W CARRUTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 04/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 PHYSICIANS DR 96 PHYSICIANS DRIVE
JACKSON TN
38305-2070
US

IV. Provider business mailing address

96 PHYSICIANS DR 96 PHYSICIANS DRIVE
JACKSON TN
38305-2070
US

V. Phone/Fax

Practice location:
  • Phone: 731-664-8771
  • Fax: 731-660-7050
Mailing address:
  • Phone: 731-664-8771
  • Fax: 731-660-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD009363
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: