1205086790 NPI number — EAST TENNESSEE COMMUNITY OPEN MRI

Table of content: (NPI 1205086790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205086790 NPI number — EAST TENNESSEE COMMUNITY OPEN MRI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TENNESSEE COMMUNITY OPEN MRI
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:
1205086790
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11664
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37939-1664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-584-7376
Provider Business Mailing Address Fax Number:
865-540-3856

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1415 OLD WEISGARBER RD
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37909-1327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-692-9964
Provider Business Practice Location Address Fax Number:
865-684-2619
Provider Enumeration Date:
09/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LANGENBERG
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
865-584-7376

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , with the licence number:  ODC0000000048 , 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: 1523020 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com