Provider Demographics
NPI:1780686436
Name:UNIVERSITY OF TENNESSEE
Entity Type:Organization
Organization Name:UNIVERSITY OF TENNESSEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-265-8220
Mailing Address - Street 1:294 SUMMAR DR
Mailing Address - Street 2:DEPT. 289
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3915
Mailing Address - Country:US
Mailing Address - Phone:731-265-8220
Mailing Address - Fax:731-265-8355
Practice Address - Street 1:294 SUMMAR DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3915
Practice Address - Country:US
Practice Address - Phone:731-423-1932
Practice Address - Fax:731-423-4919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
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
TN3375617Medicaid
TN3375617Medicaid