Individual
EDGAR LEI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
200 STONECREST BLVD, SMYRNA, TN 37167-6810
(631) 768-2000
Mailing address
200 STONECREST BLVD, SMYRNA, TN 37167-6810
(631) 768-2000
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
61513
TN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
03/28/2017
Last updated
09/10/2020
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