Provider Demographics
NPI:1023030988
Name:TENNESSEE PODIATRIC CLINICS INC
Entity Type:Organization
Organization Name:TENNESSEE PODIATRIC CLINICS INC
Other - Org Name:CORP
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO TENNESSEE PODIATRIC CLINIC INC
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:HAVERLY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:865-531-8449
Mailing Address - Street 1:PO BOX 32607
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930
Mailing Address - Country:US
Mailing Address - Phone:865-531-8449
Mailing Address - Fax:865-692-9142
Practice Address - Street 1:9330 PARK WEST BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923
Practice Address - Country:US
Practice Address - Phone:865-531-8449
Practice Address - Fax:865-692-9142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3353864Medicare ID - Type Unspecified