Provider Demographics
NPI:1669527230
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 1:3469 NEW HIGHWAY 68
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37354
Practice Address - Country:US
Practice Address - Phone:423-442-3993
Practice Address - Fax:423-442-9468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4447828Medicaid
TN152400OtherBLUECROSS BLUESHIELD TN
TN3911334Medicare ID - Type Unspecified