1730468182 NPI number — COVENANT MEDICAL GROUP, INC

Table of content: (NPI 1730468182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730468182 NPI number — COVENANT MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT MEDICAL GROUP, INC
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:
1730468182
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 CENTERPOINT BLVD
Provider Second Line Business Mailing Address:
BLDG A, STE 202
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37932-1979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-374-5200
Provider Business Mailing Address Fax Number:
865-374-5201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
423 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
LENOIR CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37772-5640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-271-6575
Provider Business Practice Location Address Fax Number:
865-986-7807
Provider Enumeration Date:
08/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
UTTERBACK
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
G
Authorized Official Title or Position:
VP FINANCIAL SERVICES
Authorized Official Telephone Number:
865-374-5119

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3734041 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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