MEDICARE: PAUL LARRY DASSOW 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	34878	KY
2	207QA0000X	Adolescent Medicine (Family Medicine) Physician	34878	KY
3	207QA0505X	Adult Medicine Physician	34878	KY
4	207QG0300X	Geriatric Medicine (Family Medicine) Physician	34878	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790729572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL LARRY DASSOW MD

Provider Business Mailing Address
First Line	:	PO BOX 11023
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37401-2023
Country	:	US
Telephone Number	:	423-778-9300
Fax Number	:	423-778-9301

Provider Business Practice Location Address
First Line	:	1100 E 3RD ST
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37403-2241
Country	:	US
Telephone Number	:	423-778-9300
Fax Number	:	423-778-9301

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

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	06/27/2012

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Directions to “ PAUL LARRY DASSOW MD” Practice Location

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