1760655179 NPI number — ANN E BLACKWOOD-WIDNER PT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760655179 NPI number — ANN E BLACKWOOD-WIDNER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKWOOD-WIDNER
Provider First Name:
ANN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLACKWOOD
Provider Other First Name:
ANN
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760655179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2725 WATER RIDGE PKWY
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28217-4580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-831-5065
Provider Business Mailing Address Fax Number:
704-831-5066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11440 PARKSIDE DR
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37934-2658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-777-3748
Provider Business Practice Location Address Fax Number:
865-777-3827
Provider Enumeration Date:
04/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  6135 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2305205029 . This is a "VIRGINIA LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 15751 . This is a "FLORIDA LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6135 . This is a "TN LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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