1497983233 NPI number — CONRAD BLAKE IVIE MD

Table of content: CONRAD BLAKE IVIE MD (NPI 1497983233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497983233 NPI number — CONRAD BLAKE IVIE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IVIE
Provider First Name:
CONRAD
Provider Middle Name:
BLAKE
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:
1497983233
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9129 CROSS PARK DR STE 101
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:
37923-4505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-694-7725
Provider Business Mailing Address Fax Number:
865-560-8525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9430 PARK WEST BLVD STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37923-4205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-690-4861
Provider Business Practice Location Address Fax Number:
865-560-8525
Provider Enumeration Date:
07/01/2009

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: 207X00000X , with the licence number:  52697 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XS0114X , with the licence number: 52697 , 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: 3376148 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".