=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770770356
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER LIN M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2007
-----------------------------------------------------
Last Update Date | 11/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 W FOREST AVE SUITE 300
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38301-3937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-422-0310
-----------------------------------------------------
Fax | 731-422-0475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 400
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38302-0400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-423-8697
-----------------------------------------------------
Fax | 731-422-5743
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | MD49088
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------