Provider Demographics
NPI:1659418598
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:POLK COUNTY HEALTH DEPARTMENT- COPPER BASIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-634-5832
Mailing Address - Street 1:840 CHEROKEE TRL
Mailing Address - Street 2:
Mailing Address - City:COPPERHILL
Mailing Address - State:TN
Mailing Address - Zip Code:37317-5200
Mailing Address - Country:US
Mailing Address - Phone:423-496-3275
Mailing Address - Fax:423-496-4442
Practice Address - Street 1:840 CHEROKEE TRL
Practice Address - Street 2:
Practice Address - City:COPPERHILL
Practice Address - State:TN
Practice Address - Zip Code:37317-5200
Practice Address - Country:US
Practice Address - Phone:423-496-3275
Practice Address - Fax:423-496-4442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3911077Medicare ID - Type UnspecifiedFLU PROVIDER NUMBER