Provider Demographics
NPI:1427102177
Name:STATE OF TENNESSEE
Entity type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:F
Authorized Official - Last Name:SHARP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-549-5266
Mailing Address - Street 1:PO BOX 59019
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-9019
Mailing Address - Country:US
Mailing Address - Phone:865-425-8800
Mailing Address - Fax:865-463-7950
Practice Address - Street 1:710 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-3143
Practice Address - Country:US
Practice Address - Phone:865-425-8800
Practice Address - Fax:865-463-7950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9408OtherBLUECROSS BLUESHIELD
TN4447838Medicaid
TN4447838Medicaid