Provider Demographics
NPI:1972124618
Name:DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES, STATE OF TN
Entity type:Organization
Organization Name:DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES, STATE OF TN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY COMMISSIONER
Authorized Official - Prefix:
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-253-6710
Mailing Address - Street 1:315 DEADERICK ST FL 8
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37238-3000
Mailing Address - Country:US
Mailing Address - Phone:615-253-6710
Mailing Address - Fax:
Practice Address - Street 1:315 DEADERICK ST FL 8
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37238-3000
Practice Address - Country:US
Practice Address - Phone:615-253-6710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES, STATE OF TN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization