Provider Demographics
NPI:1659670412
Name:COVENANT PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:COVENANT PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OMER
Authorized Official - Middle Name:
Authorized Official - Last Name:BREEDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-744-8755
Mailing Address - Street 1:421 OLD RICEVILLE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-3074
Mailing Address - Country:US
Mailing Address - Phone:423-744-8755
Mailing Address - Fax:423-744-8568
Practice Address - Street 1:421 OLD RICEVILLE RD STE 2
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3074
Practice Address - Country:US
Practice Address - Phone:423-744-8755
Practice Address - Fax:423-744-8568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-19
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD19704261QR1300X
TNMD019704208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty