Provider Demographics
NPI:1154314615
Name:OAK RIDGE GASTROENTEROLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:OAK RIDGE GASTROENTEROLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:F
Authorized Official - Last Name:LUCKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-483-4366
Mailing Address - Street 1:988 OAK RIDGE TPKE
Mailing Address - Street 2:SUITE 200, PHYSICIANS PLAZA
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6930
Mailing Address - Country:US
Mailing Address - Phone:865-483-4366
Mailing Address - Fax:865-483-5957
Practice Address - Street 1:988 OAK RIDGE TPKE
Practice Address - Street 2:SUITE 200, PHYSICIANS PLAZA
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6930
Practice Address - Country:US
Practice Address - Phone:865-483-4366
Practice Address - Fax:865-483-5957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3378494Medicare ID - Type Unspecified