1609075464 NPI number — J. GREGORY ROBERTS, MD, RVT, PC DBA MANTLE CLINIC III

Table of content: (NPI 1609075464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609075464 NPI number — J. GREGORY ROBERTS, MD, RVT, PC DBA MANTLE CLINIC III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J. GREGORY ROBERTS, MD, RVT, PC DBA MANTLE CLINIC III
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:
1609075464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10810 PARKSIDE DR STE 309
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:
37934-1986
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-218-6244
Provider Business Mailing Address Fax Number:
865-218-6245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10810 PARKSIDE DR STE 309
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:
37934-1986
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:
07/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FREELS
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRACTICE MANAGER
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 . This identifiers is of the category "OTHER".
  • Identifier: 64078132 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: TN0101 . This is a "JOHN DEERE HEALTH" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com