Basic Information
| Provider Information | |||||||||
| NPI: | 1922050475 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEARSE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | K. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | K. | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1400 DOWELL SPRINGS BLVD | ||||||||
| Address2: | STE 120 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379092450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652321415 | ||||||||
| FaxNumber: | 8652321416 | ||||||||
| Practice Location | |||||||||
| Address1: | 2910 TAZEWELL PIKE | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379181879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656871512 | ||||||||
| FaxNumber: | 8656872138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6119 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3652954 | 05 | TN | MEDICAID | 3154490 | 01 | TN | BLUE CROSS | OTHER | CH4394 | 01 | TN | MEDICARE-RAILROAD GROUP ID | OTHER |