Provider Demographics
NPI:1982929279
Name:PEDIATRIC CONSULTANTS WEST
Entity Type:Organization
Organization Name:PEDIATRIC CONSULTANTS WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROSSETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-691-3335
Mailing Address - Street 1:PO BOX 440215
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0215
Mailing Address - Country:US
Mailing Address - Phone:865-670-6199
Mailing Address - Fax:865-670-6188
Practice Address - Street 1:125 HUXLEY RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3197
Practice Address - Country:US
Practice Address - Phone:865-691-3335
Practice Address - Fax:865-691-3310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-30
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1518261Medicaid