MEDICARE: MR. LARRY ERNEST GERDOM PA-C

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	363A00000X	Physician Assistant	PA0000001329	TN

General Provider Information

NPI Number	:	1104900547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LARRY ERNEST GERDOM PA-C

Provider Business Mailing Address
First Line	:	4010 WELLINGTON CT
Second Line	:
City	:	OLD HICKORY
State	:	TN
Zip	:	37138-4657
Country	:	US
Telephone Number	:	615-758-0476
Fax Number	:	615-248-1622

Provider Business Practice Location Address
First Line	:	333 MURFREESBORO RD
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37210-2834
Country	:	US
Telephone Number	:	615-248-1261
Fax Number	:	615-248-1622

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

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/08/2007

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