=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447237714
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARENCE ALVIN HEAD MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 15TH ST ROOM 2144
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30912-0004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-424-3871
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 28068
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37424-8068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-424-3871
-----------------------------------------------------
Fax | 423-899-0928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 034154
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------