1659403590 NPI number — ADVANTAGE FAMILY HEALTHCARE, PLLC

Table of content: (NPI 1659403590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659403590 NPI number — ADVANTAGE FAMILY HEALTHCARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTAGE FAMILY HEALTHCARE, 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:
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:
1659403590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11541 KINGSTON PIKE 101
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:
37934-3918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-675-7522
Provider Business Mailing Address Fax Number:
865-671-3196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11541 KINGSTON PIKE 101
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:
37934-3918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-675-7522
Provider Business Practice Location Address Fax Number:
865-671-3196
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF MANAGER
Authorized Official Telephone Number:
865-675-7522

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , 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: 3728422 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4029196 . This is a "BCBST GROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: TN103 . This is a "UNITED HEALTH RIVER VALL" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 100034888 . This is a "PHP CARITEN ID NUMBER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 190646 . This is a "UNITED HEALTHCARE GROUP #" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 7768236 . This is a "AETNA US HEALTHCARE ID" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4050284 . This is a "BLUECROSS BLUESHIELD OF T" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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