Provider Demographics
NPI:1831308006
Name:TENNESSEE UROLOGY ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:TENNESSEE UROLOGY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-690-0602
Mailing Address - Street 1:9724 KINGSTON PIKE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3347
Mailing Address - Country:US
Mailing Address - Phone:865-690-0602
Mailing Address - Fax:865-690-0515
Practice Address - Street 1:2001 LAUREL AVE
Practice Address - Street 2:SUITE 502
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1810
Practice Address - Country:US
Practice Address - Phone:865-522-6005
Practice Address - Fax:865-546-5678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1260440003Medicare NSC