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2462 Old Fort Pkwy Murfreesboro TN 37128-4163 | |
| (931) 808-7504 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 2462 Old Fort Pkwy, Murfreesboro, Tennessee |
| Authorized Official Name and Position | Joshua Davenport (OWNER) |
| Authorized Official Contact | 6157168255 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
105 N Maple St Ste 4 Murfreesboro TN 37130-3524 Ph: (615) 716-8255 | 2462 Old Fort Pkwy Murfreesboro TN 37128-4163 Ph: (931) 808-7504 |
| NPI Number | 1568190890 |
|---|---|
| Provider Enumeration Date | 08/14/2022 |
| Last Update Date | 06/28/2024 |
| Certification Date | 06/28/2024 |
| Medicare PECOS PAC ID | 4082081518 |
|---|---|
| Medicare Enrollment ID | O20221112000051 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1568190890 | NPI | - | NPPES |
| Provider Name | Prasad V Kondapavuluru |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1265538581 PECOS PAC ID: 5991799306 Enrollment ID: I20040409000033 |
| Provider Name | Alexandra Marquese Mayes |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1669096152 PECOS PAC ID: 2466998893 Enrollment ID: I20240722003911 |
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