Provider Demographics
NPI:1154303162
Name:PARKWEST MEDICAL CENTER
Entity Type:Organization
Organization Name:PARKWEST MEDICAL CENTER
Other - Org Name:PENINSULA LIGHTHOUSE PENINSULA OUTPATIENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:GEPPI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-374-6872
Mailing Address - Street 1:PO BOX 1999
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37777-1999
Mailing Address - Country:US
Mailing Address - Phone:865-970-1295
Mailing Address - Fax:865-380-1461
Practice Address - Street 1:6800 BAUM DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-7315
Practice Address - Country:US
Practice Address - Phone:865-970-9800
Practice Address - Fax:865-380-1461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL 2(14)M5-076-1466261QM0801X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Not Answered261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0440173Medicaid
TN440173Medicare ID - Type Unspecified