Provider Demographics
| NPI: | 1457302010 |
|---|---|
| Name: | COVENANT MEDICAL GROUP, INC. |
| Entity Type: | Organization |
| Organization Name: | COVENANT MEDICAL GROUP, INC. |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | VP FINANCIAL SERVICES |
| Authorized Official - Prefix: | MS |
| Authorized Official - First Name: | JULIE |
| Authorized Official - Middle Name: | G |
| Authorized Official - Last Name: | UTTERBACK |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 865-374-5119 |
| Mailing Address - Street 1: | 1400 CENTERPOINT BLVD |
| Mailing Address - Street 2: | BLDG A, SUITE 202 |
| Mailing Address - City: | KNOXVILLE |
| Mailing Address - State: | TN |
| Mailing Address - Zip Code: | 37932-2146 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 865-374-5200 |
| Mailing Address - Fax: | 865-374-5201 |
| Practice Address - Street 1: | 1400 CENTERPOINT BLVD |
| Practice Address - Street 2: | BLDG A, SUITE 202 |
| Practice Address - City: | KNOXVILLE |
| Practice Address - State: | TN |
| Practice Address - Zip Code: | 37932-2146 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 865-374-5200 |
| Practice Address - Fax: | 865-374-5201 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-05-16 |
| Last Update Date: | 2016-12-21 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207RC0001X | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | Group - Multi-Specialty |
| No | 207RI0011X | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | Group - Multi-Specialty |
| No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
| No | 207RS0012X | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | Group - Multi-Specialty |
| No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
| No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| TN | 3734041 | Medicaid | |
| TN | 6516130004 | Medicare PIN | |
| TN | 6516130003 | Medicare PIN | |
| TN | 6516130002 | Medicare PIN | |
| TN | 3734041 | Medicare PIN | |
| TN | 6516130001 | Medicare PIN |
