Provider Demographics
NPI:1811949357
Name:MACKIEWICZ, THADDEUS JR (PT)
Entity type:Individual
Prefix:MR
First Name:THADDEUS
Middle Name:
Last Name:MACKIEWICZ
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:260 FORT SANDERS WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3355
Mailing Address - Country:US
Mailing Address - Phone:865-769-4545
Mailing Address - Fax:865-769-4501
Practice Address - Street 1:1932 ALCOA HWY
Practice Address - Street 2:SUITE 350
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1527
Practice Address - Country:US
Practice Address - Phone:865-595-1940
Practice Address - Fax:865-595-1945
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6085225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36583521Medicaid
TN4140561OtherBLUECROSS BLUESHIELD
TN0465875OtherCIGNA
TN4140561OtherBLUECROSS BLUESHIELD