Provider Demographics
NPI:1609075464
Name:J. GREGORY ROBERTS, MD, RVT, PC DBA MANTLE CLINIC III
Entity Type:Organization
Organization Name:J. GREGORY ROBERTS, MD, RVT, PC DBA MANTLE CLINIC III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FREELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-218-6244
Mailing Address - Street 1:10810 PARKSIDE DR STE 309
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-1986
Mailing Address - Country:US
Mailing Address - Phone:865-218-6244
Mailing Address - Fax:865-218-6245
Practice Address - Street 1:10810 PARKSIDE DR STE 309
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1986
Practice Address - Country:US
Practice Address - Phone:865-218-6244
Practice Address - Fax:865-218-6245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37706174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4069830OtherBCBS
KY64078132Medicaid
TNTN0101OtherJOHN DEERE HEALTH
TN=========Medicaid
TNTN0101OtherJOHN DEERE HEALTH