Basic Information
| Provider Information | |||||||||
| NPI: | 1639113061 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THOMPSON CANCER SURVIVAL CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RADIATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1915 WHITE AVE | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379162300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655411485 | ||||||||
| FaxNumber: | 8655412564 | ||||||||
| Practice Location | |||||||||
| Address1: | 1915 WHITE AVE | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379162300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655411485 | ||||||||
| FaxNumber: | 8655412564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 10/06/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | MITZI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, CFO | ||||||||
| AuthorizedOfficialTelephone: | 8655411485 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COVENANT HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0203X | 00000196 | TN | N | Ambulatory Health Care Facilities | Clinic/Center | Oncology, Radiation | 261QX0203X | 00000171 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology, Radiation |
ID Information
| ID | Type | State | Issuer | Description | 103G706246 | 01 | TN | PTAN | OTHER | 103G706246 | 05 | TN | MEDICAID |