Provider Demographics
NPI:1215982681
Name:MID - SOUTH HEART CENTER PC
Entity type:Organization
Organization Name:MID - SOUTH HEART CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:721-423-8383
Mailing Address - Street 1:48 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3947
Mailing Address - Country:US
Mailing Address - Phone:731-423-8383
Mailing Address - Fax:731-424-6309
Practice Address - Street 1:48 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3947
Practice Address - Country:US
Practice Address - Phone:731-423-8383
Practice Address - Fax:731-424-6309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33426174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3712931Medicaid
TN3712931Medicare ID - Type Unspecified