Provider Demographics
NPI:1952323982
Name:PAYNE, MARVIN G (PT)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:G
Last Name:PAYNE
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 1:4105 FORT HENRY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2240
Mailing Address - Country:US
Mailing Address - Phone:423-239-1550
Mailing Address - Fax:423-239-1544
Practice Address - Street 1:105 MEADOWVIEW RD
Practice Address - Street 2:SUITE 4
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1725
Practice Address - Country:US
Practice Address - Phone:423-844-6935
Practice Address - Fax:423-844-6937
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19832251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3652505Medicaid
TNP00183462Medicare PIN
TN3652505Medicaid