Provider Demographics
NPI:1114285400
Name:TENNESSEE INNOVATIVE MEDICAL SERVICES PLLC
Entity Type:Organization
Organization Name:TENNESSEE INNOVATIVE MEDICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:G
Authorized Official - Last Name:FUNDERBURK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-777-6880
Mailing Address - Street 1:194 MARKET PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-2337
Mailing Address - Country:US
Mailing Address - Phone:865-560-8787
Mailing Address - Fax:865-560-8784
Practice Address - Street 1:116 CONCORD RD
Practice Address - Street 2:STE 400
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2940
Practice Address - Country:US
Practice Address - Phone:865-777-6880
Practice Address - Fax:865-777-6881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1527902Medicaid
TN103G707928Medicare PIN