Provider Demographics
NPI:1053414698
Name:CROSSVILLE MEDICAL GROUP PA
Entity type:Organization
Organization Name:CROSSVILLE MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-484-5141
Mailing Address - Street 1:100 LANTANA RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-1903
Mailing Address - Country:US
Mailing Address - Phone:931-484-5141
Mailing Address - Fax:931-484-5620
Practice Address - Street 1:100 LANTANA RD
Practice Address - Street 2:SUITE 202
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-1903
Practice Address - Country:US
Practice Address - Phone:931-484-5141
Practice Address - Fax:931-484-5620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3370906Medicaid
TN3370906Medicare PIN