=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568494284
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN BRENDLE STANDRIDGE II M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2006
-----------------------------------------------------
Last Update Date | 06/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 SPEARS AVE
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-531-4265
-----------------------------------------------------
Fax | 423-531-4267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6838 BUCK TRAIL DR
-----------------------------------------------------
City | HARRISON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37341-4912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-531-4265
-----------------------------------------------------
Fax | 423-531-4267
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 9010
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 9010
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------