Provider Demographics
NPI:1144428780
Name:COVENANT MEDCARE LLC
Entity Type:Organization
Organization Name:COVENANT MEDCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:423-949-9200
Mailing Address - Street 1:PO BOX 985
Mailing Address - Street 2:15324 RANKIN AVE
Mailing Address - City:DUNLAP
Mailing Address - State:TN
Mailing Address - Zip Code:37327-0985
Mailing Address - Country:US
Mailing Address - Phone:423-949-9200
Mailing Address - Fax:423-949-9203
Practice Address - Street 1:15324 RANKIN AVENUE
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:TN
Practice Address - Zip Code:37327
Practice Address - Country:US
Practice Address - Phone:423-949-9200
Practice Address - Fax:423-949-9203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO0000001427207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3726561OtherMEDICARE PTAN
TN3726561OtherMEDICARE PTAN