1598956492 NPI number — CARRIE DIANE ELLIS-COLANDRO DO

Table of content: CARRIE DIANE ELLIS-COLANDRO DO (NPI 1598956492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598956492 NPI number — CARRIE DIANE ELLIS-COLANDRO DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS-COLANDRO
Provider First Name:
CARRIE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELLIS
Provider Other First Name:
CARRIE
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598956492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1225 E WEISGARBER RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37909-2604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-584-4747
Provider Business Mailing Address Fax Number:
865-584-1363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7541 CROSSWOOD BLVD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37924-3935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-524-1661
Provider Business Practice Location Address Fax Number:
865-523-8406
Provider Enumeration Date:
08/06/2007

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: 207Q00000X , with the licence number:  1931 , 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: 3721613 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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