=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144330606
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK P. BYRD M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 04/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2414 CHAMBLISS AVE N.W.
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-472-6581
-----------------------------------------------------
Fax | 423-472-2425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2414 CHAMBLISS AVE N.W.
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-472-6581
-----------------------------------------------------
Fax | 423-472-2425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YX0905X
-----------------------------------------------------
Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
-----------------------------------------------------
License Number | MD14726
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------