1104453588 NPI number — MARK IRWIN

Table of content: MARK IRWIN (NPI 1104453588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104453588 NPI number — MARK IRWIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IRWIN
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1104453588
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 19TH STREET
Provider Second Line Business Mailing Address:
SUITE 600, TRUSTEES TOWER
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37916
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-525-4333
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 19TH ST STE 600
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:
37916-1852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-525-4333
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/25/2020

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: 207RI0200X , with the licence number:  6170 , 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: Q102113 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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