Provider Demographics
NPI: | 1821296625 |
---|---|
Name: | FARRAGUT WALK IN CLINIC |
Entity Type: | Organization |
Organization Name: | FARRAGUT WALK IN CLINIC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | DAVID |
Authorized Official - Middle Name: | G |
Authorized Official - Last Name: | PETTY |
Authorized Official - Suffix: | JR |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 865-671-6026 |
Mailing Address - Street 1: | 11408 KINGSTON PIKE |
Mailing Address - Street 2: | SUITE 400 |
Mailing Address - City: | KNOXVILLE |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37934-3975 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 865-671-6026 |
Mailing Address - Fax: | 865-671-6062 |
Practice Address - Street 1: | 11408 KINGSTON PIKE |
Practice Address - Street 2: | SUITE 400 |
Practice Address - City: | KNOXVILLE |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37934-3975 |
Practice Address - Country: | US |
Practice Address - Phone: | 865-671-6026 |
Practice Address - Fax: | 865-671-6062 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-07-03 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TN | 305R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 305R00000X | Managed Care Organizations | Preferred Provider Organization |