Provider Demographics
NPI:1780686170
Name:UNIVERSITY OF TENNESSEE
Entity Type:Organization
Organization Name:UNIVERSITY OF TENNESSEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-448-2847
Mailing Address - Street 1:16 BRENTSHIRE SQ
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2203
Mailing Address - Country:US
Mailing Address - Phone:731-664-0994
Mailing Address - Fax:731-664-0866
Practice Address - Street 1:1301 PRIMACY PKWY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0213
Practice Address - Country:US
Practice Address - Phone:901-448-0275
Practice Address - Fax:901-448-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3713025Medicaid
TN3713025Medicaid