=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215145974
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLON AND RECTAL SURGERY CONSULTANTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2007
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1321 SUNSET DR SUITE 22
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-3698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-610-1177
-----------------------------------------------------
Fax | 423-610-1179
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1321 SUNSET DR SUITE 22
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-3698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-610-1177
-----------------------------------------------------
Fax | 423-610-1179
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CONNIE J PENNINGTON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 423-610-1177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD0000030358
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------