Physician Compare National (NPI:1053845545)

HEALTHCARE PROVIDER: GONZALO RAFAEL DE VILLA M.D.

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1053845545
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	9436426749
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20200807002982
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	DE VILLA
	Individual professional last name
Provider First Name	GONZALO
	Individual professional first name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	OTHER
	Individual professional's medical school
Graduation Year	2017
	Individual professional's medical school graduation year
Primary Specialty	FAMILY MEDICINE
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Organization Legal Name	COVENANT MEDICAL GROUP INC
	Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Group Practice PAC ID	2860305463
	Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Number of Group Practice members	222
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	102 S CHARLES G SEIVERS BLVD
	Group Practice or individual's line 1 address
City	CLINTON
	Group Practice or individual's city
State	TN
	Group Practice or individual's state
Zip Code	377163916
	Group Practice or individual's zip code (9 digits when available)
Phone Number	8654574702
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Professional Accepts Medicare Assignment	Y