Provider Demographics
NPI:1124048996
Name:STATE OF TENNESSEE
Entity type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHITWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:930-490-8334
Mailing Address - Street 1:209 S CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-3502
Mailing Address - Country:US
Mailing Address - Phone:931-363-5506
Mailing Address - Fax:931-424-7020
Practice Address - Street 1:209 S CEDAR LN
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-3502
Practice Address - Country:US
Practice Address - Phone:931-363-5506
Practice Address - Fax:931-424-7020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2007838OtherBC/BS & TENNCARE SELECT
TN4448007Medicaid
TN3068448OtherTENNCARE SELECT PCP
TN3910546Medicare ID - Type Unspecified