Provider Demographics
NPI:1306327887
Name:OPTIMUM MEN'S HEALTH PLLC
Entity type:Organization
Organization Name:OPTIMUM MEN'S HEALTH PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:JARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:615-490-5357
Mailing Address - Street 1:131 MAPLE ROW BLVD STE D400
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-3777
Mailing Address - Country:US
Mailing Address - Phone:615-991-3158
Mailing Address - Fax:
Practice Address - Street 1:131 MAPLE ROW BLVD STE D400
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-3777
Practice Address - Country:US
Practice Address - Phone:615-991-3158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1533293Medicaid