Provider Demographics
NPI:1063512390
Name:AVERETT, STEPHEN L (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:AVERETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:TN
Mailing Address - Zip Code:37096-3327
Mailing Address - Country:US
Mailing Address - Phone:931-589-2222
Mailing Address - Fax:931-589-2400
Practice Address - Street 1:62 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:TN
Practice Address - Zip Code:37096-3327
Practice Address - Country:US
Practice Address - Phone:931-589-2222
Practice Address - Fax:931-589-2400
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11696207R00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3189276Medicaid
TN3189276Medicare ID - Type Unspecified
TN3189276Medicaid