Provider Demographics
NPI:1316970742
Name:KJELLIN, INGRID (MD)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:KJELLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 N PETERS RD
Mailing Address - Street 2:STE 225
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-2327
Mailing Address - Country:US
Mailing Address - Phone:865-694-0062
Mailing Address - Fax:
Practice Address - Street 1:8 CADILLAC DR
Practice Address - Street 2:STE 200
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-5087
Practice Address - Country:US
Practice Address - Phone:615-376-7360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA501532085R0202X
TN429872085R0202X
OH35.0930972085R0202X
IN01064511A2085R0202X
IL0361220032085R0202X
NC2010-004242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A501530Medicaid
TN3001106Medicaid
00A501530Medicare ID - Type Unspecified
CA00A501530Medicaid
F96758Medicare UPIN