1336115419 NPI number — THOMAS J EBERTS MD

Table of content: THOMAS J EBERTS MD (NPI 1336115419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336115419 NPI number — THOMAS J EBERTS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EBERTS
Provider First Name:
THOMAS
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1336115419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11784
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:
37939-1784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-588-2928
Provider Business Mailing Address Fax Number:
865-450-9374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
137 BLOUNT AVE
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:
37871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-632-5992
Provider Business Practice Location Address Fax Number:
865-632-5316
Provider Enumeration Date:
02/27/2006

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: 207ZP0102X , with the licence number:  21500 , 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: 1140104 . This is a "UHC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3063693 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4011837 . This is a "BCBS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 64721434 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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