Provider Demographics
NPI:1053430439
Name:TULLAHOMA INTERNAL MEDICINE, PLLC
Entity type:Organization
Organization Name:TULLAHOMA INTERNAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RIMDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-393-3366
Mailing Address - Street 1:PO BOX 1896
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-1896
Mailing Address - Country:US
Mailing Address - Phone:931-393-3366
Mailing Address - Fax:931-393-1065
Practice Address - Street 1:1330 CEDAR LN
Practice Address - Street 2:SUITE 100
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2283
Practice Address - Country:US
Practice Address - Phone:931-393-3366
Practice Address - Fax:931-393-1065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000027908207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNMD27908OtherLICENSE NUMBER
TN1679566772OtherIND NPI NUMBER
TN3810510Medicaid
TN3810510Medicare ID - Type UnspecifiedINDIVIDUAL
TN3810510Medicaid
TN3372968Medicare ID - Type UnspecifiedGROUP NUMBER