Provider Demographics
NPI:1740332220
Name:SOUTHERN MEDICAL GROUP PLLC
Entity type:Organization
Organization Name:SOUTHERN MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KANIPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-632-5885
Mailing Address - Street 1:6600 NIGHTINGALE LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2754
Mailing Address - Country:US
Mailing Address - Phone:865-632-5885
Mailing Address - Fax:865-632-5893
Practice Address - Street 1:6600 NIGHTINGALE LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2754
Practice Address - Country:US
Practice Address - Phone:865-632-5885
Practice Address - Fax:865-632-5893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN611721701OtherFEDERAL BALCK LUNG
TN3733309Medicare ID - Type Unspecified