Provider Demographics
NPI:1366589335
Name:STATE OF TENNESSEEE
Entity type:Organization
Organization Name:STATE OF TENNESSEEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:423-634-5832
Mailing Address - Street 1:1301 RIVERFRONT PKWY STE 209
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-3312
Mailing Address - Country:US
Mailing Address - Phone:423-634-5832
Mailing Address - Fax:423-634-3186
Practice Address - Street 1:334 FRAZIER ST
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37367-4926
Practice Address - Country:US
Practice Address - Phone:423-447-2149
Practice Address - Fax:423-447-6777
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF TENNESSEE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-31
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3910968Medicare ID - Type UnspecifiedFLU PROVIDER NUMBER