Provider Demographics
NPI:1972084069
Name:EDMUNDS GASTROENTEROLOGY, PLLC
Entity type:Organization
Organization Name:EDMUNDS GASTROENTEROLOGY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-740-1095
Mailing Address - Street 1:4713 PAPERMILL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1924
Mailing Address - Country:US
Mailing Address - Phone:865-851-7771
Mailing Address - Fax:865-851-7835
Practice Address - Street 1:4713 PAPERMILL DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-1908
Practice Address - Country:US
Practice Address - Phone:865-851-7771
Practice Address - Fax:865-851-7835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-27
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD26426207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ008655Medicaid