Provider Demographics
NPI:1821523101
Name:ENSEMBLE MEDICAL PLLC
Entity Type:Organization
Organization Name:ENSEMBLE MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEAVER
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHATTUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-633-9068
Mailing Address - Street 1:PO BOX 5777
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-5777
Mailing Address - Country:US
Mailing Address - Phone:865-246-2104
Mailing Address - Fax:865-246-2106
Practice Address - Street 1:417 HOLLY ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-7815
Practice Address - Country:US
Practice Address - Phone:865-633-9068
Practice Address - Fax:865-246-2106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-25
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty