Provider Demographics
NPI:1588941942
Name:CLARKSVILLE SPORTSMED & WELLNESS
Entity type:Organization
Organization Name:CLARKSVILLE SPORTSMED & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SYED
Authorized Official - Middle Name:AHMED
Authorized Official - Last Name:NASEERUDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-645-6990
Mailing Address - Street 1:2690 MADISON ST
Mailing Address - Street 2:STE 130
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5975
Mailing Address - Country:US
Mailing Address - Phone:931-645-6990
Mailing Address - Fax:931-245-1720
Practice Address - Street 1:2690 MADISON STREET
Practice Address - Street 2:STE 130
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5458
Practice Address - Country:US
Practice Address - Phone:931-645-6990
Practice Address - Fax:931-245-1720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-12
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN15967363LF0000X
TNMD45045207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4324612OtherBCBSTN
TN1527840Medicaid
TN1527840Medicaid