Provider Demographics
NPI:1952792111
Name:NEW SOUTH MEDICAL
Entity type:Organization
Organization Name:NEW SOUTH MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-645-5595
Mailing Address - Street 1:2292 DALTON DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8960
Mailing Address - Country:US
Mailing Address - Phone:931-645-5595
Mailing Address - Fax:931-645-5596
Practice Address - Street 1:2292 DALTON DR
Practice Address - Street 2:SUITE C
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8960
Practice Address - Country:US
Practice Address - Phone:931-645-5595
Practice Address - Fax:931-645-5596
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW SOUTH MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29433174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN024236OtherLICENSE
TN29433OtherMEDICAL LICENSE