Provider Demographics
NPI:1861462426
Name:CORRELL, GEOFFREY GRATTAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:GRATTAN
Last Name:CORRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:109 MEADOWVIEW RD
Practice Address - Street 2:SUITE 3
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1669
Practice Address - Country:US
Practice Address - Phone:423-968-2446
Practice Address - Fax:423-968-7223
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2013-04-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TNMD27152207Q00000X
VA0101054051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005600227Medicaid
TN3812114Medicare PIN
VAVV9274BMedicare PIN
TNG52762Medicare UPIN
TN080098477Medicare PIN
TN103I082929Medicare PIN