Basic Information
| Provider Information | |||||||||
| NPI: | 1043856677 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAC OF TENNESSEE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 6TH ST STE 256 | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376202257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235731502 | ||||||||
| FaxNumber: | 4232170604 | ||||||||
| Practice Location | |||||||||
| Address1: | 1958 WEST STATE STREET | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376202257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235731502 | ||||||||
| FaxNumber: | 4232170604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2019 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | HOLBROOK | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4235731502 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.