Healthcare Provider Details

I. General information

NPI: 1386382273
Provider Name (Legal Business Name): THE CENTER FOR PEDIATRIC EXCELLENCE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2022
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 STONECREST BLVD STE 250
SMYRNA TN
37167-6832
US

IV. Provider business mailing address

300 STONECREST BLVD STE 250
SMYRNA TN
37167-6832
US

V. Phone/Fax

Practice location:
  • Phone: 629-220-0211
  • Fax: 629-220-0210
Mailing address:
  • Phone: 629-220-0211
  • Fax: 629-220-0210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DEREK KEITH JOHNSON
Title or Position: CEO
Credential: MD
Phone: 615-785-9303