1467999532 NPI number — TENNESSEE RIVER PHYSICIANS, PLLC

Table of content: (NPI 1467999532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467999532 NPI number — TENNESSEE RIVER PHYSICIANS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENNESSEE RIVER PHYSICIANS, 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:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1467999532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20882
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-874-5400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
71 WHEELERTOWN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIKEVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37367-5246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-447-2112
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
LARSEN
Authorized Official First Name:
KIM
Authorized Official Middle Name:
H
Authorized Official Title or Position:
DIRECTOR OF CREDENTIALING
Authorized Official Telephone Number:
770-874-5400

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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