Provider Demographics
NPI:1881852648
Name:HIDAY, JUSTIN WAYNE (PT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WAYNE
Last Name:HIDAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 FORT SANDERS WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3355
Mailing Address - Country:US
Mailing Address - Phone:865-769-4500
Mailing Address - Fax:
Practice Address - Street 1:7557 DANNAHER WAY
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3558
Practice Address - Country:US
Practice Address - Phone:865-512-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT8009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508067Medicaid
TN4202023OtherBLUECROSS BLUESHIELD
3711622OtherMEDICARE PTAN
3711622OtherMEDICARE PTAN