Provider Demographics
NPI:1013958917
Name:ROBERTS, JACK T JR (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:T
Last Name:ROBERTS
Suffix:JR
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 1:103 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4703
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:907 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5015
Practice Address - Country:US
Practice Address - Phone:865-980-4897
Practice Address - Fax:865-977-4793
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN09957207R00000X
TNMD09957208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3161933Medicaid
D70184Medicare UPIN
TN103I119182Medicare PIN