Provider Demographics
NPI:1336100445
Name:MMDS OF KNOXVILLE, LLC
Entity type:Organization
Organization Name:MMDS OF KNOXVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:G
Authorized Official - Last Name:TJADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:823-250-2830
Mailing Address - Street 1:710 MABRY HOOD RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-2661
Mailing Address - Country:US
Mailing Address - Phone:865-671-6637
Mailing Address - Fax:
Practice Address - Street 1:710 MABRY HOOD RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37932-2661
Practice Address - Country:US
Practice Address - Phone:865-671-6637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3044463Medicaid
TN3404463OtherMEDICARE