Provider Demographics
NPI:1679512693
Name:PLATEAU MEDICAL GROUP PC
Entity type:Organization
Organization Name:PLATEAU MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KASAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-248-5646
Mailing Address - Street 1:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38557-1028
Mailing Address - Country:US
Mailing Address - Phone:931-248-5646
Mailing Address - Fax:
Practice Address - Street 1:421 S MAIN ST
Practice Address - Street 2:CUMBERLAND MEDICAL CENTER
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-5048
Practice Address - Country:US
Practice Address - Phone:931-484-9511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000035488207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3373590Medicare ID - Type Unspecified