Provider Demographics
NPI:1629103635
Name:J. GREGORY ROBERTS MD RVT
Entity Type:Organization
Organization Name:J. GREGORY ROBERTS MD RVT
Other - Org Name:MANTLE CLINIC III
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD RVT
Authorized Official - Phone:865-218-6244
Mailing Address - Street 1:1728 FALCON POINTE DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-6397
Mailing Address - Country:US
Mailing Address - Phone:865-742-3063
Mailing Address - Fax:865-218-6244
Practice Address - Street 1:223 ANDREW DR
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:TN
Practice Address - Zip Code:37841
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:2007-02-22
Last Update Date:2020-08-22
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
TNRAILROAD MEDICAREOtherRAILROAD MEDICARE
TN$$$$$$$$$OtherSOCIAL SECURITY NUMBER
TNBCBSOther4069830
TN64078132OtherKENTUCKY MEDICAID
TNBCBSOther4069830