1790312866 NPI number — BENJAMIN ANDREW FOGELSON

Table of content: BENJAMIN ANDREW FOGELSON (NPI 1790312866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790312866 NPI number — BENJAMIN ANDREW FOGELSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOGELSON
Provider First Name:
BENJAMIN
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1790312866
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1924 ALCOA HIGHWAY
Provider Second Line Business Mailing Address:
MEDICAL BUILDING B, SUITE 127
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37920-1511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-305-9410
Provider Business Mailing Address Fax Number:
865-305-8261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1924 ALCOA HWY # U-114
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:
37920-1511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-305-9340
Provider Business Practice Location Address Fax Number:
865-305-9144
Provider Enumeration Date:
03/26/2020

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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