Basic Information
| Provider Information | |||||||||
| NPI: | 1811225410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 256 FORT SANDERS WEST BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652319481 | ||||||||
| FaxNumber: | 8657694501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 LAKE LOUDON BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379164009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659741900 | ||||||||
| FaxNumber: | 8659741259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2009 | ||||||||
| LastUpdateDate: | 03/07/2017 | ||||||||
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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 | 2251S0007X | 07778 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2255A2300X | 01075 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | 7778 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1521623 | 05 | TN | MEDICAID | 4277896 | 01 | TN | BLUECROSS BLUESHIELD | OTHER |