Provider Demographics
NPI:1194088112
Name:PREMIERCARE TENNESSEE INC
Entity type:Organization
Organization Name:PREMIERCARE TENNESSEE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-876-2200
Mailing Address - Street 1:603 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-3548
Mailing Address - Country:US
Mailing Address - Phone:407-876-2200
Mailing Address - Fax:407-876-3065
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:5 WEST
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4294
Practice Address - Country:US
Practice Address - Phone:931-783-2570
Practice Address - Fax:931-783-2579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000011394283Q00000X
TNI000000012016283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
444022Medicare Oscar/Certification