Basic Information
| Provider Information | |||||||||
| NPI: | 1811949357 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACKIEWICZ | ||||||||
| FirstName: | THADDEUS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 260 FORT SANDERS WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657694545 | ||||||||
| FaxNumber: | 8657694501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1932 ALCOA HWY | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655951940 | ||||||||
| FaxNumber: | 8655951945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 04/22/2013 | ||||||||
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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 | 225100000X | 6085 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 36583521 | 05 | TN | MEDICAID | 4140561 | 01 | TN | BLUECROSS BLUESHIELD | OTHER | 0465875 | 01 | TN | CIGNA | OTHER |