Provider Demographics
NPI:1407240971
Name:KNOXVILLE OMNICARE, PLLC
Entity Type:Organization
Organization Name:KNOXVILLE OMNICARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER, FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:UNGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-934-8385
Mailing Address - Street 1:1201 SOUTHBREEZE CIR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-8441
Mailing Address - Country:US
Mailing Address - Phone:865-934-8385
Mailing Address - Fax:
Practice Address - Street 1:1924 ALCOA HWY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1511
Practice Address - Country:US
Practice Address - Phone:865-305-5510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN49026261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10308I6537OtherMEDICARE ID