Basic Information
| Provider Information | |||||||||
| NPI: | 1083923197 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY HEALTH SYSTEM, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UT INTERNAL MEDICINE JEFFERSON CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 440476 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372440476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706199 | ||||||||
| FaxNumber: | 8656706188 | ||||||||
| Practice Location | |||||||||
| Address1: | 1413 RUSSELL AVE | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377602562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706199 | ||||||||
| FaxNumber: | 8656706188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2010 | ||||||||
| LastUpdateDate: | 06/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | MARQUART | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8653059886 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1521415 | 05 | TN | MEDICAID |