Basic Information
| Provider Information | |||||||||
| NPI: | 1013485697 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TENNESSEE CANCER SPECIALIST PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 E HILL AVE STE 230 | ||||||||
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| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379152565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8658620998 | ||||||||
| FaxNumber: | 8655441861 | ||||||||
| Practice Location | |||||||||
| Address1: | 2607 KINGSTON PIKE STE 100 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379193343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656932255 | ||||||||
| FaxNumber: | 8656917888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2018 | ||||||||
| LastUpdateDate: | 11/13/2018 | ||||||||
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| AuthorizedOfficialLastName: | JENKINS | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8658620998 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 3725737 | 05 | TN | MEDICAID |