Provider Demographics
NPI:1184629735
Name:ADVANTAGE FAMILY HEALTHCARE, PLLC
Entity Type:Organization
Organization Name:ADVANTAGE FAMILY HEALTHCARE, PLLC
Other - Org Name:CAMPBELL STATION PRIMARY CARE ASSOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MANAGER / PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CFNP
Authorized Official - Phone:865-675-7522
Mailing Address - Street 1:11541 KINGSTON PIKE
Mailing Address - Street 2:STE 101
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-3918
Mailing Address - Country:US
Mailing Address - Phone:865-675-7522
Mailing Address - Fax:865-671-3196
Practice Address - Street 1:11541 KINGSTON PIKE
Practice Address - Street 2:STE 101
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-3918
Practice Address - Country:US
Practice Address - Phone:865-675-7522
Practice Address - Fax:865-671-3196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-19
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN7953363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3908484Medicaid
44D0993636OtherCLIA ID NUMBER
1659403590OtherGROUP NPI
1922004159OtherINDIVIDUAL NPI
1659403590OtherGROUP NPI
P19355Medicare UPIN
3908484Medicare ID - Type UnspecifiedPERFORMING PROVIDER #