Provider Demographics
NPI:1093760902
Name:INTERNAL MEDICINE AND PEDIATRIC ASSOC OF BRISTOL
Entity Type:Organization
Organization Name:INTERNAL MEDICINE AND PEDIATRIC ASSOC OF BRISTOL
Other - Org Name:INTERNAL MEDICINE AND PEDIATRIC ASSOCIATES OF BRISTOL PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-844-6704
Mailing Address - Street 1:350 STEELES RD STE 2
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-9532
Mailing Address - Country:US
Mailing Address - Phone:423-844-6700
Mailing Address - Fax:423-844-6703
Practice Address - Street 1:350 STEELES ROAD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-9532
Practice Address - Country:US
Practice Address - Phone:423-844-6700
Practice Address - Fax:423-844-6703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207Q00000X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDCG2912OtherMEDICARE RAILROAD
TN3707101OtherTNCARE PN
SDCG2912OtherMEDICARE RAILROAD #
TN=========OtherFEDERAL TAX ID#
TN=========OtherFEDERAL TAX ID#