Basic Information
Provider Information | |||||||||
NPI: | 1194008474 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY HEALTH SYSTEM, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COLE NEUROSCIENCE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 440105 | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372440105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8656706199 | ||||||||
FaxNumber: | 8656706188 | ||||||||
Practice Location | |||||||||
Address1: | 1928 ALCOA HWY | ||||||||
Address2: | STE 102 | ||||||||
City: | KNOXVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 379201502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8653056640 | ||||||||
FaxNumber: | 8653056745 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2011 | ||||||||
LastUpdateDate: | 01/10/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARQUART | ||||||||
AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
AuthorizedOfficialMiddleName: | B. | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8653059886 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 1525461 | 05 | TN |   | MEDICAID |