Basic Information
| Provider Information | |||||||||
| NPI: | 1679876411 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLOUNT HOSPITALISTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4068 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378024068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731752 | ||||||||
| FaxNumber: | 8652731755 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 E LAMAR ALEXANDER PKWY | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659804897 | ||||||||
| FaxNumber: | 8659774796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2010 | ||||||||
| LastUpdateDate: | 03/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | SHATTUCK | ||||||||
| AuthorizedOfficialFirstName: | DEAVER | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8659804897 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1522060 | 05 | TN | MEDICAID |