Basic Information
| Provider Information | |||||||||
| NPI: | 1588655880 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROFFITT | ||||||||
| FirstName: | WILMA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24776 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374224776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772881799 | ||||||||
| FaxNumber: | 4238925838 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 E LAMAR ALEXANDER PKWY | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659837211 | ||||||||
| FaxNumber: | 8654509374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 12/02/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25501 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 3131612 | 01 | TN | BLUE CROSS BLUE SHIELD TN | OTHER | 3091120 | 05 | TN | MEDICAID |