Basic Information
| Provider Information | |||||||||
| NPI: | 1093920787 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FENTRESS HEALTH SYSTEMS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51923 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379501923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655316070 | ||||||||
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| Practice Location | |||||||||
| Address1: | 208 W CENTRAL AVENUE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317522273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 06/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | ALLRED | ||||||||
| AuthorizedOfficialFirstName: | BALEY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CHARIMAN OF THE BOARD | ||||||||
| AuthorizedOfficialTelephone: | 9317522273 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | 34 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | 3790001 | 05 | TN | MEDICAID | TN0101 | 01 | AMERICHOICE | OTHER |