Provider Demographics
NPI:1265570170
Name:STATE OF TENNESSEE
Entity type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:F
Authorized Official - Last Name:SHARP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-549-5266
Mailing Address - Street 1:PO BOX 59019
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-9019
Mailing Address - Country:US
Mailing Address - Phone:865-549-5266
Mailing Address - Fax:865-594-8919
Practice Address - Street 1:931 INDUSTRIAL PARK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DANDRIDGE
Practice Address - State:TN
Practice Address - Zip Code:37725-4701
Practice Address - Country:US
Practice Address - Phone:865-397-3930
Practice Address - Fax:865-397-1246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4447831Medicaid
TN150560OtherBLUECROSSBLUESHIELD TN
TN4447831Medicaid