1265570170 NPI number — STATE OF TENNESSEE

Table of content: (NPI 1265570170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265570170 NPI number — STATE OF TENNESSEE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF TENNESSEE
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:
6
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:
1265570170
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 59019
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:
37950-9019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-549-5266
Provider Business Mailing Address Fax Number:
865-594-8919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
931 INDUSTRIAL PARK RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
DANDRIDGE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37725-4701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-397-3930
Provider Business Practice Location Address Fax Number:
865-397-1246
Provider Enumeration Date:
02/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHARP
Authorized Official First Name:
MARIANNE
Authorized Official Middle Name:
F
Authorized Official Title or Position:
REGIONAL ACCOUNTANT
Authorized Official Telephone Number:
865-549-5266

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4447831 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 150560 . This is a "BLUECROSSBLUESHIELD TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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