1184629735 NPI number — ADVANTAGE FAMILY HEALTHCARE, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184629735 NPI number — ADVANTAGE FAMILY HEALTHCARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTAGE FAMILY HEALTHCARE, PLLC
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:
CAMPBELL STATION PRIMARY CARE ASSOC
Provider Other Organization Name Type Code:
3
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:
1184629735
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11541 KINGSTON PIKE
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37934-3918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-675-7522
Provider Business Mailing Address Fax Number:
865-671-3196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11541 KINGSTON PIKE
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37934-3918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-675-7522
Provider Business Practice Location Address Fax Number:
865-671-3196
Provider Enumeration Date:
06/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
CHIEF MANAGER / PROVIDER
Authorized Official Telephone Number:
865-675-7522

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  APN7953 , 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: 3908484 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 44D0993636 . This is a "CLIA ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1659403590 . This is a "GROUP NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1922004159 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".




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