Provider Demographics
NPI:1376759852
Name:TENNESSEE BREAST CENTER, INC
Entity Type:Organization
Organization Name:TENNESSEE BREAST CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:E
Authorized Official - Last Name:TREKELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD,FACS, MBA
Authorized Official - Phone:856-984-9282
Mailing Address - Street 1:1111 E LAMAR ALEXANDER PKWY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5130
Mailing Address - Country:US
Mailing Address - Phone:865-984-9282
Mailing Address - Fax:865-981-1716
Practice Address - Street 1:1111 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5130
Practice Address - Country:US
Practice Address - Phone:865-984-9282
Practice Address - Fax:865-981-1716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN02346362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3730971Medicaid
TN3730971Medicare ID - Type Unspecified