Basic Information
| Provider Information | |||||||||
| NPI: | 1922039429 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY HEALTH SYSTEM, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UT PRIMARY CARE LENOIR CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415000-MSC8137 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372418137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706199 | ||||||||
| FaxNumber: | 8656706198 | ||||||||
| Practice Location | |||||||||
| Address1: | 5779 CREEKWOOD PARK BLVD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | LENOIR | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706750 | ||||||||
| FaxNumber: | 8659888772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 06/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | MAYNARD | ||||||||
| AuthorizedOfficialFirstName: | BETH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8656706754 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32851413 | 05 | TN | MEDICAID |