Provider Demographics
NPI:1336199645
Name:MARYVILLE ANESTHESIOLOGISTS PC
Entity Type:Organization
Organization Name:MARYVILLE ANESTHESIOLOGISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:E
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-983-7211
Mailing Address - Street 1:PO BOX 3181
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3181
Mailing Address - Country:US
Mailing Address - Phone:855-381-0344
Mailing Address - Fax:800-731-0751
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:865-983-7211
Practice Address - Fax:855-917-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNCL8433OtherRR
TN3378283Medicaid
TN3604498Medicaid
TN3378283Medicare PIN
TNCL8433Medicare PIN
TN3378283Medicaid