Provider Demographics
NPI:1750485322
Name:PSYCHIATRIC ASSOCIATES OF KINGSPORT LLP
Entity Type:Organization
Organization Name:PSYCHIATRIC ASSOCIATES OF KINGSPORT LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D. PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOFFET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-392-6500
Mailing Address - Street 1:444 CLINCHFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3859
Mailing Address - Country:US
Mailing Address - Phone:423-392-6500
Mailing Address - Fax:423-392-6504
Practice Address - Street 1:444 CLINCHFIELD ST STE 101
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3859
Practice Address - Country:US
Practice Address - Phone:423-392-6500
Practice Address - Fax:423-392-6504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000164942084P0800X
TNMD00000206202084P0800X
TNMD00000137972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA069099OtherMOFFET BCVA
TN3189819Medicaid
TN0105831OtherMOFFET BCTN
TN0018152OtherSMITH BCTN
VA069098OtherSMITH BCVA
VA069097OtherKUTTY BC VA
TN3052859Medicaid
TN0048066OtherKUTTY BC TN
TN3016081Medicaid
TN3701225Medicare ID - Type UnspecifiedSMITH
TN0018152OtherSMITH BCTN
TN0048066OtherKUTTY BC TN
E43376Medicare UPIN
TN3701225Medicare ID - Type UnspecifiedMOFFET
TN3052859Medicaid