MEDICARE: PEDIATRIC PLACE OF UNION CITY LLC

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	208000000X	Pediatrics Physician	42330	TN

General Provider Information

NPI Number	:	1578762647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC PLACE OF UNION CITY LLC

Provider Business Mailing Address
First Line	:	1613 STONEHEDGE BLVD
Second Line	:
City	:	UNION CITY
State	:	TN
Zip	:	38261-5976
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1117 S MILES AVE
Second Line	:	SUITE 3
City	:	UNION CITY
State	:	TN
Zip	:	38261-5439
Country	:	US
Telephone Number	:	731-885-4338
Fax Number	:	731-885-4339

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	DR. JOHN B BATES
Credential	:	M.D.
Telephone Number	:	731-885-4338

Provider Enumeration Date	:	07/17/2007
Last Update Date	:	07/17/2007

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