Provider Demographics
NPI:1083923197
Name:UNIVERSITY HEALTH SYSTEM, INC
Entity Type:Organization
Organization Name:UNIVERSITY HEALTH SYSTEM, INC
Other - Org Name:UT INTERNAL MEDICINE JEFFERSON CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARQUART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-305-9886
Mailing Address - Street 1:PO BOX 440476
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0476
Mailing Address - Country:US
Mailing Address - Phone:865-670-6199
Mailing Address - Fax:865-670-6188
Practice Address - Street 1:1413 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2562
Practice Address - Country:US
Practice Address - Phone:865-670-6199
Practice Address - Fax:865-670-6188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1521415Medicaid
TN1521415Medicaid
TNDR0947Medicare PIN