Provider Demographics
NPI:1376587790
Name:BRANDON, MIRIAM (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:BRANDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E WEISGARBER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2604
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:
Practice Address - Street 1:7744 CONNER ROAD
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3568
Practice Address - Country:US
Practice Address - Phone:865-546-9751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36668207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00019002OtherRR MEDICARE
TN3706634Medicare ID - Type UnspecifiedLEGACY GROUP
H83486Medicare UPIN
TN3881718Medicare ID - Type UnspecifiedLEGACY PIN