Basic Information
| Provider Information | |||||||||
| NPI: | 1700195153 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE INFUSION CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4015 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376024015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239151126 | ||||||||
| FaxNumber: | 4239150635 | ||||||||
| Practice Location | |||||||||
| Address1: | 1936 BROOKSIDE DR | ||||||||
| Address2: | SUITE D | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239434790 | ||||||||
| FaxNumber: | 8885053632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2010 | ||||||||
| LastUpdateDate: | 01/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | HIREN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4239151126 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 37711 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 3886961 | 05 | TN | MEDICAID |