Basic Information
Provider Information | |||||||||
NPI: | 1053398107 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ENGBLOM | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | ARTHUR | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 256 FORT SANDERS WEST BLVD | ||||||||
Address2: |   | ||||||||
City: | KNOXVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 379223355 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8657694500 | ||||||||
FaxNumber: | 8657694572 | ||||||||
Practice Location | |||||||||
Address1: | 90 VERMONT AVE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | OAK RIDGE | ||||||||
State: | TN | ||||||||
PostalCode: | 378306474 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8654812541 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/29/2005 | ||||||||
LastUpdateDate: | 06/02/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | DPM338 | TN | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 3351783 | 05 | TN |   | MEDICAID | 480026064 | 01 | TN | RAILROAD MEDICARE | OTHER | 6035392 | 01 | TN | BCBS TN | OTHER |