Provider Demographics
NPI:1073557492
Name:WHEATLEY, HUBERT C (MD)
Entity Type:Individual
Prefix:
First Name:HUBERT
Middle Name:C
Last Name:WHEATLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E WEISGARBER RD
Mailing Address - Street 2:STE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2604
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:
Practice Address - Street 1:1124 FOX MEADOWS BLVD
Practice Address - Street 2:STE 3
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-6927
Practice Address - Country:US
Practice Address - Phone:865-428-0312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11974207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN110014992OtherRR MEDICARE PIN
TN3009768Medicaid
A97406Medicare UPIN
TN3009768Medicaid
TN3706633Medicare ID - Type UnspecifiedLEGACY GROUP