1396979936 NPI number — BENJAMIN P DALTON MD

Table of content: BENJAMIN P DALTON MD (NPI 1396979936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396979936 NPI number — BENJAMIN P DALTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DALTON
Provider First Name:
BENJAMIN
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1396979936
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 440395
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37244-0395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-670-6199
Provider Business Mailing Address Fax Number:
865-670-6198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1928 ALCOA HWY
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37920-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-305-6570
Provider Business Practice Location Address Fax Number:
865-305-6576
Provider Enumeration Date:
05/12/2009

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: 207RG0100X , with the licence number:  53046 , 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: Q016273 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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