Basic Information
| Provider Information | |||||||||
| NPI: | 1801849674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EMERY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 111 W STONE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376606027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232475197 | ||||||||
| FaxNumber: | 4232475254 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W STONE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376606027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232475197 | ||||||||
| FaxNumber: | 4232475254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 08/06/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 19732 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 0094319 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 65906208 | 05 | KY | MEDICAID | 065196 | 01 | VA | ANTHEM | OTHER | 100023382 | 01 | TN | PHP TENN CARE | OTHER | 1000908 | 05 | TN | MEDICAID | 62134825601 | 01 | TN | JOHN DEERE HEALTHCARE | OTHER | Z101 | 01 | TN | UNITED HEALTHCARE OF THE RIVER VALLEY | OTHER | 006040209 | 01 | VA | VIRGINIA MEDICAID | OTHER | 3047487 | 05 | TN | MEDICAID | 1736855 | 01 | TN | UNITED HEALTHCARE | OTHER | 5141032 | 01 | TN | AETNA | OTHER | 64798580 | 01 | KY | KENTUCKY MEDICAID | OTHER |