Provider Demographics
NPI:1003039223
Name:CEDAR CREEK PEDIATRIC & ADOLESCENT MEDICINE, PC
Entity Type:Organization
Organization Name:CEDAR CREEK PEDIATRIC & ADOLESCENT MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:R
Authorized Official - Last Name:LINGINFELTER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:865-379-2277
Mailing Address - Street 1:616 SMITHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-6100
Mailing Address - Country:US
Mailing Address - Phone:865-379-2277
Mailing Address - Fax:865-379-1171
Practice Address - Street 1:616 SMITHVIEW DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-6100
Practice Address - Country:US
Practice Address - Phone:865-379-2277
Practice Address - Fax:865-379-1191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty