Healthcare Provider Details

I. General information

NPI: 1164241006
Provider Name (Legal Business Name): PATH MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1994 GALLATIN PIKE N
MADISON TN
37115-2026
US

IV. Provider business mailing address

1994 GALLATIN PIKE N
MADISON TN
37115-2026
US

V. Phone/Fax

Practice location:
  • Phone: 561-860-1478
  • Fax:
Mailing address:
  • Phone: 561-860-1478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KENIA KANE
Title or Position: OFFICE MANAGER
Credential:
Phone: 561-860-1478