Provider Demographics
NPI:1730468182
Name:COVENANT MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:COVENANT MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCIAL SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:UTTERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-374-5119
Mailing Address - Street 1:1400 CENTERPOINT BLVD
Mailing Address - Street 2:BLDG A, STE 202
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-1979
Mailing Address - Country:US
Mailing Address - Phone:865-374-5200
Mailing Address - Fax:865-374-5201
Practice Address - Street 1:423 MEDICAL PARK DR
Practice Address - Street 2:STE 100
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5640
Practice Address - Country:US
Practice Address - Phone:865-271-6575
Practice Address - Fax:865-986-7807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3734041Medicaid
6516130002Medicare NSC
TN3734041Medicare PIN