MEDICARE: DR. GURU PADMAKAR MEDAM MD

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	207Q00000X	Family Medicine Physician	MD2013-0703	NM
2	207Q00000X	Family Medicine Physician	55403	TN

General Provider Information

NPI Number	:	1437464336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GURU PADMAKAR MEDAM MD

Provider Business Mailing Address
First Line	:	264 NEW SHACKLE ISLAND RD STE 107
Second Line	:
City	:	HENDERSONVILLE
State	:	TN
Zip	:	37075-2481
Country	:	US
Telephone Number	:	615-824-4244
Fax Number	:	615-824-5916

Provider Business Practice Location Address
First Line	:	264 NEW SHACKLE ISLAND RD STE 107
Second Line	:
City	:	HENDERSONVILLE
State	:	TN
Zip	:	37075-2481
Country	:	US
Telephone Number	:	615-824-4244
Fax Number	:	615-824-5916

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

Provider Enumeration Date	:	08/16/2010
Last Update Date	:	09/09/2021

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