Provider Demographics
NPI:1912048596
Name:KNOXVILLE MEDICAL CENTER PC
Entity Type:Organization
Organization Name:KNOXVILLE MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:KING
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:865-524-2743
Mailing Address - Street 1:1826 AILOR AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37921-5802
Mailing Address - Country:US
Mailing Address - Phone:865-524-2743
Mailing Address - Fax:865-673-4971
Practice Address - Street 1:1826 AILOR AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37921-5802
Practice Address - Country:US
Practice Address - Phone:865-524-2743
Practice Address - Fax:865-673-4971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherFEDERAL TAX ID
=========OtherFEDERAL TAX ID