Provider Demographics
NPI:1215145974
Name:COLON AND RECTAL SURGERY CONSULTANTS, PC
Entity type:Organization
Organization Name:COLON AND RECTAL SURGERY CONSULTANTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-610-1177
Mailing Address - Street 1:1321 SUNSET DR
Mailing Address - Street 2:SUITE 22
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-3698
Mailing Address - Country:US
Mailing Address - Phone:423-610-1177
Mailing Address - Fax:423-610-1179
Practice Address - Street 1:1321 SUNSET DR
Practice Address - Street 2:SUITE 22
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-3698
Practice Address - Country:US
Practice Address - Phone:423-610-1177
Practice Address - Fax:423-610-1179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000030358174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3370584Medicaid
TN=========OtherEIN
H69589Medicare UPIN
TN=========OtherEIN