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General NPI Number Information
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NPI Number | 1265554091
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Entity Type | Organization
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Legal Business Name | MID-STATE GASTROENTEROLOGY, PLLC
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Dates
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Enumeration Date | 04/04/2007
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Last Update Date | 08/26/2008
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Provider Practice Location Address
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Address Line | 517 HIGHLAND TER STE B
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City | MURFREESBORO
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State | TN
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Zip | 37130-2476
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Country | US
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Telephone | 615-896-6996
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Fax | 615-896-6985
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Provider Business Mailing Address
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Address Line | PO BOX 11209
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City | MURFREESBORO
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State | TN
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Zip | 37129-0025
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Country | US
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Telephone | 615-896-6996
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Fax | 615-896-6985
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | ROSALIND BROOK BURNETT
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Credential | M.A.
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Telephone | 615-896-6996
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD0000026198
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License Number State | TN
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