1811593460 NPI number — DR. ADOLPHUS HAYWARD PELLEY ED

Table of content: DR. ADOLPHUS HAYWARD PELLEY ED (NPI 1811593460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811593460 NPI number — DR. ADOLPHUS HAYWARD PELLEY ED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELLEY
Provider First Name:
ADOLPHUS
Provider Middle Name:
HAYWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ED
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PELLEY
Provider Other First Name:
DICK
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1811593460
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 W SPRINGDALE AVE
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:
37917-5158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-637-9711
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2336 CONGRESS PKWY S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37303-2820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-266-6751
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/09/2020

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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