Provider Demographics
NPI:1770751216
Name:TENNESSEE UROLOGY ASSOCIATES, PLLC
Entity type:Organization
Organization Name:TENNESSEE UROLOGY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-690-0602
Mailing Address - Street 1:9724 KINGSTON PIKE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3347
Mailing Address - Country:US
Mailing Address - Phone:865-690-0602
Mailing Address - Fax:865-690-0515
Practice Address - Street 1:800 OAK RIDGE TPKE
Practice Address - Street 2:SUITE A101
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6957
Practice Address - Country:US
Practice Address - Phone:865-483-1093
Practice Address - Fax:865-482-8629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1260440002Medicare NSC