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General NPI Number Information
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NPI Number | 1588941942
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Entity Type | Organization
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Legal Business Name | CLARKSVILLE SPORTSMED & WELLNESS
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Dates
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Enumeration Date | 11/12/2011
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Last Update Date | 06/20/2012
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Provider Practice Location Address
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Address Line | 2690 MADISON STREET STE 130
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City | CLARKSVILLE
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State | TN
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Zip | 37043-5458
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Country | US
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Telephone | 931-645-6990
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Fax | 931-245-1720
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Provider Business Mailing Address
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Address Line | 2690 MADISON ST STE 130
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City | CLARKSVILLE
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State | TN
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Zip | 37043-5975
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Country | US
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Telephone | 931-645-6990
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Fax | 931-245-1720
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. SYED AHMED NASEERUDDIN
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Credential | MD
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Telephone | 931-645-6990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | APN15967
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | MD45045
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License Number State | TN
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