Provider Demographics
NPI:1053575472
Name:TENNESSEE PLATEAU ONCOLOGY PLLC
Entity type:Organization
Organization Name:TENNESSEE PLATEAU ONCOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-484-7596
Mailing Address - Street 1:33 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4836
Mailing Address - Country:US
Mailing Address - Phone:931-484-7596
Mailing Address - Fax:931-484-7597
Practice Address - Street 1:33 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4836
Practice Address - Country:US
Practice Address - Phone:931-484-7596
Practice Address - Fax:931-484-7597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD21772174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00102649OtherRR MEDICARE
TN3890077Medicaid
TND05458Medicare UPIN
TNP00102649OtherRR MEDICARE