=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487616942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATTENTUS OF SCOTT COUNTY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2006
-----------------------------------------------------
Last Update Date | 03/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18797 ALBERTA ST
-----------------------------------------------------
City | ONEIDA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37841-2127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-569-2121
-----------------------------------------------------
Fax | 423-569-8640
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4609
-----------------------------------------------------
City | ONEIDA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37841-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-569-7918
-----------------------------------------------------
Fax | 423-569-8640
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOM
-----------------------------------------------------
Name | GARY M. CROSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-569-8521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------