Provider Demographics
NPI:1730101734
Name:MARYVILLE FOOT CLINIC INC
Entity Type:Organization
Organization Name:MARYVILLE FOOT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:C
Authorized Official - Last Name:HEGERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-681-6667
Mailing Address - Street 1:1515 E LAMAR ALEXANDER PKWY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5131
Mailing Address - Country:US
Mailing Address - Phone:865-982-2119
Mailing Address - Fax:865-984-5642
Practice Address - Street 1:1515 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5131
Practice Address - Country:US
Practice Address - Phone:865-982-2119
Practice Address - Fax:865-984-5642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN564213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNTN0101OtherJOHN DEERE
TN7404093OtherAETNA
TN3732878Medicaid
TN1231208OtherCIGNA
TN4118088OtherBCBS OF TN
TNBNA2743006OtherUNITED HEALTHCARE
TN7404093OtherAETNA
TN=========OtherFISERV HEALTH
TNTN0101OtherJOHN DEERE
TN=========OtherTRICARE SOUTH
TN=========OtherHUMANA
TNBNA2743006OtherUNITED HEALTHCARE
TN=========OtherHEALTH COST SOLUTIONS