Provider Demographics
NPI:1306864186
Name:KNOXVILLE KIDNEY CENTER, PLLC
Entity Type:Organization
Organization Name:KNOXVILLE KIDNEY CENTER, PLLC
Other - Org Name:G. EDWARD NEWMAN, MD, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CONGER
Authorized Official - Suffix:
Authorized Official - Credentials:CCRC
Authorized Official - Phone:865-692-3462
Mailing Address - Street 1:320 PARK 40 NORTH BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-3624
Mailing Address - Country:US
Mailing Address - Phone:865-692-3462
Mailing Address - Fax:865-692-3463
Practice Address - Street 1:320 PARK 40 NORTH BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-3624
Practice Address - Country:US
Practice Address - Phone:865-692-3462
Practice Address - Fax:865-692-3463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 207RN0300X
TN32138261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN004125050OtherBLUECROSS BLUESHIELD OF TN
TNDE8488OtherPGBA RAILROAD MEDICARE
TNG90737Medicare UPIN
TNDE8488OtherPGBA RAILROAD MEDICARE