1619012507 NPI number — WOODROW W GWINN JR

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619012507 NPI number — WOODROW W GWINN JR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODROW W GWINN JR
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:
1619012507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1812 E LAMAR ALEXANDER PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37804-5283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-977-0916
Provider Business Mailing Address Fax Number:
865-984-3519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
259 N PETERS RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37923-4923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-690-6898
Provider Business Practice Location Address Fax Number:
865-690-9481
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GWINN JR
Authorized Official First Name:
WOODROW
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
865-977-0916

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC0000000336 , 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: 3732364 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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