=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154823078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHATTANOOGA LUNG SPECIALISTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2018
-----------------------------------------------------
Last Update Date | 03/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6714 HERITAGE BUSINESS CT
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37421-2596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-693-9477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6714 HERITAGE BUSINESS CT
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37421-2596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR/PHYSICAN
-----------------------------------------------------
Name | MANIE RAVEE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 423-693-9477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 41412
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------