Provider Demographics
NPI:1376943878
Name:DRS BLACK&BENTON PEDIATRICS
Entity Type:Organization
Organization Name:DRS BLACK&BENTON PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KESTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OM
Authorized Official - Phone:865-687-1940
Mailing Address - Street 1:4741 N BROADWAY ST STE B
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-1793
Mailing Address - Country:US
Mailing Address - Phone:865-687-1940
Mailing Address - Fax:865-687-0157
Practice Address - Street 1:4741 N BROADWAY ST STE B
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-1793
Practice Address - Country:US
Practice Address - Phone:865-687-1940
Practice Address - Fax:865-687-0157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD17837261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care