Basic Information
| Provider Information | |||||||||
| NPI: | 1215392030 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GI FOR KIDS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 888260 | ||||||||
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| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379958260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706199 | ||||||||
| FaxNumber: | 8656706198 | ||||||||
| Practice Location | |||||||||
| Address1: | 1975 TOWN CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379226638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655463998 | ||||||||
| FaxNumber: | 8655461123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2015 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | AL-TAWIL | ||||||||
| AuthorizedOfficialFirstName: | YOUHANNA | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8655463998 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | TN | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 2080P0206X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | Q018806 | 05 | TN | MEDICAID |