Basic Information
Provider Information | |||||||||
NPI: | 1104811694 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANN | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | III | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 105 W STONE DR | ||||||||
Address2: | SUITE 6A | ||||||||
City: | KINGSPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 376603365 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234087220 | ||||||||
FaxNumber: | 4234087405 | ||||||||
Practice Location | |||||||||
Address1: | 130 W RAVINE RD | ||||||||
Address2: |   | ||||||||
City: | KINGSPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 376603837 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4232308206 | ||||||||
FaxNumber: | 4232308502 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2005 | ||||||||
LastUpdateDate: | 01/08/2014 | ||||||||
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 | 207R00000X | 053656 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 43439 | TN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 43439 | TN | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | 0101254459 | VA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 0101254459 | VA | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 7100058980 | 05 | KY |   | MEDICAID | 100001094C | 05 | GA |   | MEDICAID | 1104811694 | 05 | VA |   | MEDICAID | 52484938 | 01 |   | BCBSGA | OTHER | 1507594 | 05 | TN |   | MEDICAID |