Provider Demographics
NPI:1376737791
Name:LOVETT P REDDICK MD PC
Entity Type:Organization
Organization Name:LOVETT P REDDICK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOVETT
Authorized Official - Middle Name:P
Authorized Official - Last Name:REDDICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-247-8104
Mailing Address - Street 1:2008 BROOKSIDE DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4604
Mailing Address - Country:US
Mailing Address - Phone:423-247-8104
Mailing Address - Fax:423-247-9732
Practice Address - Street 1:2008 BROOKSIDE DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4604
Practice Address - Country:US
Practice Address - Phone:423-247-8104
Practice Address - Fax:423-247-9732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD11963208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3182118Medicaid
TN3182118Medicaid
3383216Medicare PIN