Provider Demographics
NPI:1891798641
Name:MONNIG, JACK A (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:MONNIG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 W ANDREW JOHNSON HWY
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3216
Mailing Address - Country:US
Mailing Address - Phone:423-587-8009
Mailing Address - Fax:423-289-1607
Practice Address - Street 1:2845 W ANDREW JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3216
Practice Address - Country:US
Practice Address - Phone:423-587-8009
Practice Address - Fax:423-289-1607
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000007871208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4130585OtherBCBS
TN3176988Medicaid
TN4130585OtherBCBS
TN3176988Medicaid