1093760902 NPI number — INTERNAL MEDICINE AND PEDIATRIC ASSOC OF BRISTOL

Table of content: (NPI 1093760902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093760902 NPI number — INTERNAL MEDICINE AND PEDIATRIC ASSOC OF BRISTOL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE AND PEDIATRIC ASSOC OF BRISTOL
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:
INTERNAL MEDICINE AND PEDIATRIC ASSOCIATES OF BRISTOL PC
Provider Other Organization Name Type Code:
3
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:
1093760902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 STEELES RD STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37620-9532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-844-6700
Provider Business Mailing Address Fax Number:
423-844-6703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 STEELES ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37620-9532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-844-6700
Provider Business Practice Location Address Fax Number:
423-844-6703
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOODY
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
423-844-6704

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CG2912 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 3707101 . This is a "TNCARE PN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: CG2912 . This is a "MEDICARE RAILROAD #" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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