1336175736 NPI number — VINCENT A. VISCOMI, MD PC

Table of content: (NPI 1336175736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336175736 NPI number — VINCENT A. VISCOMI, MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VINCENT A. VISCOMI, MD PC
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:
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:
1336175736
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 24325
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37422-4325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-495-7378
Provider Business Mailing Address Fax Number:
423-495-4425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 GLENWOOD DRIVE
Provider Second Line Business Practice Location Address:
SUITE E-680
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37404-1176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-495-7378
Provider Business Practice Location Address Fax Number:
423-495-4425
Provider Enumeration Date:
06/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VISCOMI
Authorized Official First Name:
VINCENT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
423-495-7378

Provider Taxonomy Codes

  • Taxonomy code: 207RC0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3049230 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DG8484 . This is a "RR MEDICARE TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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