MEDICARE: TEDDY HARMON DAVIS CRNA

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	367500000X	Certified Registered Nurse Anesthetist	APN0000017383	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01286073	OTHER	NC	MEDICARE RR

General Provider Information

NPI Number	:	1194162966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEDDY HARMON DAVIS CRNA

Provider Business Mailing Address
First Line	:	2204 PAVILION DR STE 300
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37660-4653
Country	:	US
Telephone Number	:	423-857-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2204 PAVILION DR STE 300
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37660-4653
Country	:	US
Telephone Number	:	423-857-7000
Fax Number	:

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

Provider Enumeration Date	:	06/03/2013
Last Update Date	:	07/15/2015

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