1083615553 NPI number — WOODROW W GWINN JR. D.C.

Table of content: WOODROW W GWINN JR. D.C. (NPI 1083615553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083615553 NPI number — WOODROW W GWINN JR. D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GWINN
Provider First Name:
WOODROW
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
D.C.
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:
1083615553
Entity Type Code:
Individual
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:
1812 E LAMAR ALEXANDER PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37804-5283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-977-0916
Provider Business Mailing Address Fax Number:
865-984-3519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1812 E LAMAR ALEXANDER PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37804-5283
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-977-0916
Provider Business Practice Location Address Fax Number:
865-984-3519
Provider Enumeration Date:
08/09/2005

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: 111N00000X , with the licence number:  845 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: DC336 , 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: 350013505 . This is a "RAILROAD MEDICARE NUMBER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3674835 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3674838 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4111719 . This is a "BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4159000 . This is a "BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3072063 . This is a "BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 97802 . This is a "BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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