=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154596120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DONALD TUCKER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2008
-----------------------------------------------------
Last Update Date | 08/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 WILLIAM NORTHERN BLVD
-----------------------------------------------------
City | TULLAHOMA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37388-4754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-454-0489
-----------------------------------------------------
Fax | 931-454-2348
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 WILLIAM NORTHERN BLVD
-----------------------------------------------------
City | TULLAHOMA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-454-0489
-----------------------------------------------------
Fax | 931-454-2348
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | DONALD V TUCKER JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 931-454-0489
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD024197
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------