Provider Demographics
NPI:1629271085
Name:AVATAR MEDICAL INC.
Entity Type:Organization
Organization Name:AVATAR MEDICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-977-1818
Mailing Address - Street 1:241 E WATT ST
Mailing Address - Street 2:
Mailing Address - City:ALCOA
Mailing Address - State:TN
Mailing Address - Zip Code:37701-2236
Mailing Address - Country:US
Mailing Address - Phone:865-977-1818
Mailing Address - Fax:865-977-1801
Practice Address - Street 1:241 E WATT ST
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-2236
Practice Address - Country:US
Practice Address - Phone:865-977-1818
Practice Address - Fax:865-977-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34883207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3725067Medicare ID - Type Unspecified