=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215266135
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUBIN BURT PRATER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2009
-----------------------------------------------------
Last Update Date | 12/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HIGHWAY 58 - GALLAHER ROAD K-1007, MS-7422
-----------------------------------------------------
City | OAK RIDGE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37831-4699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-574-8562
-----------------------------------------------------
Fax | 865-241-4636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11187 BIG CANOE
-----------------------------------------------------
City | BIG CANOE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30143-5102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-367-1700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 35891
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------