Basic Information
| Provider Information | |||||||||
| NPI: | 1699775718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONGLETON | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9041 EXECUTIVE PARK DR STE 112 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656900602 | ||||||||
| FaxNumber: | 8656900515 | ||||||||
| Practice Location | |||||||||
| Address1: | 7557 DANNAHER DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378493563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659385222 | ||||||||
| FaxNumber: | 8659385264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 10/02/2017 | ||||||||
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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 | 208800000X | MD0000020494 | TN | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 020253199 | 01 | TN | EEOICP | OTHER | 3106070 | 01 | TN | BLUE CROSS | OTHER | 1669416442 | 01 | TN | GROUP NPI | OTHER | CI2260 | 01 | TN | RAILROAD MEDICARE | OTHER | 3052785 | 05 | TN | MEDICAID | 3106079 | 01 | TN | BLUE CROSS | OTHER |