Basic Information
Provider Information | |||||||||
NPI: | 1922080936 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PARKWEST MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PENINSULA OUTPATIENT CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1999 | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 377771999 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8659701295 | ||||||||
FaxNumber: | 8653801461 | ||||||||
Practice Location | |||||||||
Address1: | 423 MEDICAL PARK DR | ||||||||
Address2: |   | ||||||||
City: | LENOIR CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 377725640 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8659709800 | ||||||||
FaxNumber: | 8653801461 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GEPPI | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT CFO | ||||||||
AuthorizedOfficialTelephone: | 8653746872 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | L 214-076-1468 | TN | X |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QR0405X | L 214-076-1468 | TN | X |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
ID | Type | State | Issuer | Description | 0440173 | 05 | TN |   | MEDICAID |