Provider Demographics
NPI:1386797058
Name:STATE OF TENNESSEE
Entity type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-650-7000
Mailing Address - Street 1:2629 FAIRVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:TN
Mailing Address - Zip Code:37062-9084
Mailing Address - Country:US
Mailing Address - Phone:615-799-2389
Mailing Address - Fax:615-799-2260
Practice Address - Street 1:2629 FAIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:TN
Practice Address - Zip Code:37062-9084
Practice Address - Country:US
Practice Address - Phone:615-799-2389
Practice Address - Fax:615-799-2260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4448313Medicaid
TN3910428Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER