1356486252 NPI number — J. GREGORY ROBERTS MD RVT

Table of content: (NPI 1356486252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356486252 NPI number — J. GREGORY ROBERTS MD RVT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J. GREGORY ROBERTS MD RVT
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:
MANTLE CLINIC III
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:
1356486252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1728 FALCON POINTE DR
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:
37922-6397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-438-0096
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10810 PARKSIDE DR
Provider Second Line Business Practice Location Address:
SUITE 309
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37934-1979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-218-6244
Provider Business Practice Location Address Fax Number:
865-218-6245
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
GREGORY
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
865-218-6244

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  37706 , 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: 4069830 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: $$$$$$$$$ . This is a "SOCIAL SECURITY NUMBER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 64078132 . This is a "KENTUCKY MEDICAID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: DA9327 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com