Provider Demographics
NPI:1346283553
Name:ENDERSON, BLAINE L (MD)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:L
Last Name:ENDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 440473
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0473
Mailing Address - Country:US
Mailing Address - Phone:865-670-6199
Mailing Address - Fax:865-670-6188
Practice Address - Street 1:1924 ALCOA HWY
Practice Address - Street 2:U114
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1511
Practice Address - Country:US
Practice Address - Phone:865-305-9340
Practice Address - Fax:865-305-9231
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000181902086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3028291Medicaid
TN3028290Medicaid
TN3028291Medicaid
TN3028290Medicaid