=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922029586
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN C BOMAR JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2006
-----------------------------------------------------
Last Update Date | 06/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1044 STATE HWY 48
-----------------------------------------------------
City | CUMBERLAND FURNACE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-341-7432
-----------------------------------------------------
Fax | 615-789-6596
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 MORNING MIST LN STE 1
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37064-8657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-240-3681
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 026130
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------