Provider Demographics
NPI:1215968300
Name:SORCE, ANGELO J (MD)
Entity type:Individual
Prefix:
First Name:ANGELO
Middle Name:J
Last Name:SORCE
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 1:120 HOSPITAL DR STE G20
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-5284
Mailing Address - Country:US
Mailing Address - Phone:865-475-5103
Mailing Address - Fax:865-475-5106
Practice Address - Street 1:120 HOSPITAL DR STE G20
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-5284
Practice Address - Country:US
Practice Address - Phone:865-475-5103
Practice Address - Fax:865-475-5106
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN57940207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104371052Medicaid
MI2003000582OtherBCBS PROVIDER NUMBER
MI300027028OtherTAX ID NUMBER
MI2008274161OtherBCBS#
TNBS7447344OtherDEA