Provider Demographics
NPI:1821201112
Name:NEWPORT INTERNAL MEDICINE, PC
Entity Type:Organization
Organization Name:NEWPORT INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:VICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-623-0601
Mailing Address - Street 1:235 MURRAY DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-3631
Mailing Address - Country:US
Mailing Address - Phone:423-623-0601
Mailing Address - Fax:423-623-3842
Practice Address - Street 1:235 MURRAY DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3631
Practice Address - Country:US
Practice Address - Phone:423-623-0601
Practice Address - Fax:423-623-3842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15147207R00000X
TN26134207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3715433Medicaid
TN3715433Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER