Healthcare Provider Details

I. General information

NPI: 1356561856
Provider Name (Legal Business Name): NORTHCREST PHYSICIAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 NORTHCREST DR 430 NORTHCREST DR
SPRINGFIELD TN
37172-3973
US

IV. Provider business mailing address

PO BOX 969
SPRINGFIELD TN
37172-0969
US

V. Phone/Fax

Practice location:
  • Phone: 615-382-5710
  • Fax: 615-382-5776
Mailing address:
  • Phone: 615-382-5710
  • Fax: 615-382-5776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24985
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number31309
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD6465
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number37667
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number31565
License Number StateTN

VIII. Authorized Official

Name: JERLYN S DAVIS
Title or Position: BILLER
Credential:
Phone: 615-382-5710