=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942747365
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALSAM PARTNERS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2017
-----------------------------------------------------
Last Update Date | 01/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 203 W HIGH ST # 24
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37190-1147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 629-777-5969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 203 W HIGH ST # 24
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37190-1147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 629-777-5969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JEFFREY LEE TODD
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 629-777-5969
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 38269
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------