=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124321062
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOMENTUM MEDICAL GROUP PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2010
-----------------------------------------------------
Last Update Date | 04/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1910 CHURCH ST 2ND FLOOR (SUITE 200)
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37203-2204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-208-9010
-----------------------------------------------------
Fax | 615-208-9020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 680245
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37068-0245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-208-9010
-----------------------------------------------------
Fax | 615-208-9020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KENT VAN SICKLE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 615-208-9010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------