Basic Information
| Provider Information | |||||||||
| NPI: | 1700109402 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY HEALTH SYSTEM, INC | ||||||||
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| OtherOrganizationName: | UT FAMILY PHYSICIANS LOUDON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 440227 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372440227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706199 | ||||||||
| FaxNumber: | 8656706188 | ||||||||
| Practice Location | |||||||||
| Address1: | 2480 HWY 72 N | ||||||||
| Address2: | |||||||||
| City: | LOUDON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654581183 | ||||||||
| FaxNumber: | 8654587920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2010 | ||||||||
| LastUpdateDate: | 09/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | MARQUART | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 8653059886 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1518345 | 05 | TN | MEDICAID |