Provider Demographics
NPI:1093920787
Name:FENTRESS HEALTH SYSTEMS, LLC
Entity Type:Organization
Organization Name:FENTRESS HEALTH SYSTEMS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHARIMAN OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:BALEY
Authorized Official - Middle Name:F
Authorized Official - Last Name:ALLRED
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:931-752-2273
Mailing Address - Street 1:PO BOX 51923
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-1923
Mailing Address - Country:US
Mailing Address - Phone:865-531-6070
Mailing Address - Fax:
Practice Address - Street 1:208 W CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:TN
Practice Address - Zip Code:38556
Practice Address - Country:US
Practice Address - Phone:931-752-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3790001Medicaid
TN0101OtherAMERICHOICE
TN3790001Medicare PIN