Provider Demographics
NPI:1164795159
Name:TENNESSEE NEPHROLOGY CLINIC, PLLC
Entity Type:Organization
Organization Name:TENNESSEE NEPHROLOGY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:JAVEED
Authorized Official - Last Name:SHAFI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-982-5044
Mailing Address - Street 1:PO BOX 4156
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-4156
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:350 BMH PHYSICIANS OFFICE BLDG
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5819
Practice Address - Country:US
Practice Address - Phone:865-982-5044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD30912207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G708981Medicare PIN