Healthcare Provider Details

I. General information

NPI: 1306831417
Provider Name (Legal Business Name): TULLAHOMA ORTHOPAEDICS & SPORTS MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 N WASHINGTON ST SUITE 100
TULLAHOMA TN
37388-2222
US

IV. Provider business mailing address

1816 N WASHINGTON ST SUITE 100
TULLAHOMA TN
37388-2222
US

V. Phone/Fax

Practice location:
  • Phone: 931-455-8676
  • Fax: 931-455-9983
Mailing address:
  • Phone: 931-455-8676
  • Fax: 931-455-9983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY R STEVENS
Title or Position: PARTNER
Credential: DO
Phone: 931-455-8676