Provider Demographics
NPI:1093907370
Name:CEDAR BLUFF FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:CEDAR BLUFF FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:865-539-2873
Mailing Address - Street 1:9221 MIDDLEBROOK PIKE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37931-4764
Mailing Address - Country:US
Mailing Address - Phone:865-539-2873
Mailing Address - Fax:865-539-2969
Practice Address - Street 1:9221 MIDDLEBROOK PIKE
Practice Address - Street 2:SUITE 102
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37931-4764
Practice Address - Country:US
Practice Address - Phone:865-539-2873
Practice Address - Fax:865-539-2969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3377367Medicare PIN