Basic Information
| Provider Information | |||||||||
| NPI: | 1477649226 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY HEALTH SYSTEM, INC | ||||||||
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| OtherOrganizationName: | UT FAMILY PHYSICIANS NORTHSHORE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 440525 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372440525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706199 | ||||||||
| FaxNumber: | 8656706158 | ||||||||
| Practice Location | |||||||||
| Address1: | 9625 KROGER PARK DR | ||||||||
| Address2: | STE 400 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379225880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655392411 | ||||||||
| FaxNumber: | 8655392412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 06/24/2011 | ||||||||
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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 | 207Q00000X | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3710173 | 05 | TN | MEDICAID |