Provider Demographics
NPI:1407295587
Name:PRODIGAL PRIMARY CARE
Entity Type:Organization
Organization Name:PRODIGAL PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRICKHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:865-288-3754
Mailing Address - Street 1:2911 ESSARY DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-2468
Mailing Address - Country:US
Mailing Address - Phone:865-288-3754
Mailing Address - Fax:865-254-2250
Practice Address - Street 1:9221 MIDDLEBROOK PIKE
Practice Address - Street 2:SUITE 102
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37931-4764
Practice Address - Country:US
Practice Address - Phone:865-288-3754
Practice Address - Fax:865-539-2969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G702305Medicare UPIN