Provider Demographics
NPI:1386899300
Name:CORDOVA PSYCHIATRIC ASSOCIATES
Entity type:Organization
Organization Name:CORDOVA PSYCHIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HESSELRODE
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:901-737-4565
Mailing Address - Street 1:8289 CORDOVA RD #106
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016
Mailing Address - Country:US
Mailing Address - Phone:901-737-4565
Mailing Address - Fax:901-737-4312
Practice Address - Street 1:993 CORDOVA STATION AVE
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-6317
Practice Address - Country:US
Practice Address - Phone:901-737-4565
Practice Address - Fax:901-737-4312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000007462251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN=========Medicare UPIN