Basic Information
| Provider Information | |||||||||
| NPI: | 1710180062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY GASTROENTEROLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 888197 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379958197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706199 | ||||||||
| FaxNumber: | 8656706198 | ||||||||
| Practice Location | |||||||||
| Address1: | 1928 ALCOA HWY | ||||||||
| Address2: | STE 100 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653056570 | ||||||||
| FaxNumber: | 8653056576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 01/25/2017 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8653056570 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 3707009 | 05 | TN | MEDICAID |