Basic Information
| Provider Information | |||||||||
| NPI: | 1073823407 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COVENANT MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 CENTERPOINT BLVD | ||||||||
| Address2: | BLDG A, STE 202 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379321979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653745121 | ||||||||
| FaxNumber: | 8653749004 | ||||||||
| Practice Location | |||||||||
| Address1: | 629 MIDDLE CREEK RD | ||||||||
| Address2: | |||||||||
| City: | SEVIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378625014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657744440 | ||||||||
| FaxNumber: | 8657744868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2010 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | UTTERBACK | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8653745119 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 27646 | TN | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 3734041 | 05 | TN | MEDICAID |