Provider Demographics
NPI:1073823407
Name:COVENANT MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:COVENANT MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCIAL SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:UTTERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-374-5119
Mailing Address - Street 1:1400 CENTERPOINT BLVD
Mailing Address - Street 2:BLDG A, STE 202
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-1979
Mailing Address - Country:US
Mailing Address - Phone:865-374-5121
Mailing Address - Fax:865-374-9004
Practice Address - Street 1:629 MIDDLE CREEK RD
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-5014
Practice Address - Country:US
Practice Address - Phone:865-774-4440
Practice Address - Fax:865-774-4868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-19
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27646174400000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3734041Medicaid
TN3734041Medicaid
TN3734041Medicare PIN
TN6516130004OtherMEDICARE PTAN