Provider Demographics
NPI:1215965710
Name:MATHERNE, CRAIG (MD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:
Last Name:MATHERNE
Suffix:
Gender:
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:PO BOX 632476
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2476
Mailing Address - Country:US
Mailing Address - Phone:423-794-5520
Mailing Address - Fax:423-282-6940
Practice Address - Street 1:301 MED TECH PKWY
Practice Address - Street 2:STE 240
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-794-5520
Practice Address - Fax:423-282-6940
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30967207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1532440Medicaid
TN30967OtherMEDICAL LICENSE
LA1558729Medicaid
TN1532440Medicaid
LAH01255Medicare UPIN
LAH01255Medicare UPIN