MEDICARE: MRS. VLATKA SPLAJT PLYMALE D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	0000002417	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0000002417	OTHER	TN	MEDICAL LISCENCE

General Provider Information

NPI Number	:	1104113018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VLATKA SPLAJT PLYMALE D.O.

Provider Business Mailing Address
First Line	:	5979 DESERT STORM AVE
Second Line	:
City	:	FORT CAMPBELL
State	:	KY
Zip	:	42223-5585
Country	:	US
Telephone Number	:	270-412-8698
Fax Number	:	270-412-8698

Provider Business Practice Location Address
First Line	:	5979 DESERT STORM AVE
Second Line	:
City	:	FORT CAMPBELL
State	:	KY
Zip	:	42223-5585
Country	:	US
Telephone Number	:	270-412-8698
Fax Number	:	270-412-8698

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2011
Last Update Date	:	10/09/2012

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