Basic Information
| Provider Information | |||||||||
| NPI: | 1467458885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YIUM | ||||||||
| FirstName: | JACKSON | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 E 3RD ST | ||||||||
| Address2: | BOX 338 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236489808 | ||||||||
| FaxNumber: | 4236484570 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 E 3RD ST | ||||||||
| Address2: | STE 208 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237782550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 8325 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 3154099 | 05 | TN | MEDICAID |