Basic Information
| Provider Information | |||||||||
| NPI: | 1407858897 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF TENNESSEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 BRENTSHIRE SQ | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383052203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316640994 | ||||||||
| FaxNumber: | 7316640866 | ||||||||
| Practice Location | |||||||||
| Address1: | 1999 HIGHWAY 51 S | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380193630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014764457 | ||||||||
| FaxNumber: | 9014754389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PORTER | ||||||||
| AuthorizedOfficialFirstName: | JOAN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7316640994 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3713024 | 05 | TN | MEDICAID |