Provider Demographics
NPI:1215915921
Name:HEWGLEY, III, ISHAM C (MD)
Entity type:Individual
Prefix:
First Name:ISHAM
Middle Name:C
Last Name:HEWGLEY, III
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10820 PARKSIDE DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-1956
Mailing Address - Country:US
Mailing Address - Phone:865-218-7972
Mailing Address - Fax:865-218-7973
Practice Address - Street 1:10820 PARKSIDE DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1956
Practice Address - Country:US
Practice Address - Phone:865-218-7972
Practice Address - Fax:865-218-7973
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16850208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3025422Medicaid
TNP00986579OtherRR MEDICARE
TN103I111303Medicare PIN
TN3025422Medicaid