Basic Information
| Provider Information | |||||||||
| NPI: | 1508848516 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARKWEST MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PENINSULA OUTPATIENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1999 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659701295 | ||||||||
| FaxNumber: | 8653801461 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 N HENDERSON AVE | ||||||||
| Address2: | |||||||||
| City: | SEVIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659709800 | ||||||||
| FaxNumber: | 8653801461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GEPPI | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT CFO | ||||||||
| AuthorizedOfficialTelephone: | 8653746872 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | L 214-076-1470 | TN | X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QR0405X | L 214-076-1470 | TN | X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 0440173 | 05 | TN | MEDICAID |