Provider Demographics
NPI:1851629828
Name:COVENANT MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:COVENANT MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCIAL SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:UTTERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-374-5119
Mailing Address - Street 1:1400 CENTERPOINT BLVD
Mailing Address - Street 2:SUITE 202, BLDG A
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-1979
Mailing Address - Country:US
Mailing Address - Phone:865-374-5200
Mailing Address - Fax:865-374-5201
Practice Address - Street 1:1320 OLD WEISGARBER RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-1291
Practice Address - Country:US
Practice Address - Phone:865-584-2146
Practice Address - Fax:865-584-9660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6516130003Medicare NSC
TN3734041Medicare PIN
TN6516130004Medicare PIN