=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295558484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHSTAR MEDICAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2024
-----------------------------------------------------
Last Update Date | 11/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 351 DOVER RD
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37042-4144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-552-4495
-----------------------------------------------------
Fax | 931-552-0121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 351 DOVER RD
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37042-4144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-552-4495
-----------------------------------------------------
Fax | 931-552-0121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF PHYSICIAN
-----------------------------------------------------
Name | DR. WILLIAM R CARNEY JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 615-891-0202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------