1699710194 NPI number — BLOUNT MEMORIAL PHYSICIAN GROUP, INC.

Table of content: (NPI 1699710194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699710194 NPI number — BLOUNT MEMORIAL PHYSICIAN GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOUNT MEMORIAL PHYSICIAN GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699710194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 WEST BROADWAY AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37801-4703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-273-1752
Provider Business Mailing Address Fax Number:
865-273-1755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
266 JOULE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALCOA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37701-2422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-984-3864
Provider Business Practice Location Address Fax Number:
865-380-4095
Provider Enumeration Date:
06/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
INTERMITTENT CEO
Authorized Official Telephone Number:
865-977-5531

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3373710 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".