Provider Demographics
NPI:1346288966
Name:SOUTHWELL, CLYDE O (MD)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:O
Last Name:SOUTHWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-239-2018
Mailing Address - Fax:
Practice Address - Street 1:102 WESSINGTON PL
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-3085
Practice Address - Country:US
Practice Address - Phone:615-822-2214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43085174400000X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No174400000XOther Service ProvidersSpecialist
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902491Medicaid
SCN01356OtherSC MEDICAID PROVIDER#
NC0404464OtherEVERCARE
NC14014OtherBCBS PROVIDER#
NC184386OtherMEDCOST PROVIDER#
NCFH2967215OtherFCC PROVIDER#
NCP00278679OtherPALMETTO GBA PROVIDER#
NCP00278679OtherPALMETTO GBA PROVIDER#
NCH72472Medicare UPIN