Provider Demographics
NPI:1427151406
Name:PIGEON FORGE MEDICAL CLINIC
Entity type:Organization
Organization Name:PIGEON FORGE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-453-1924
Mailing Address - Street 1:3342 PARKWAY
Mailing Address - Street 2:
Mailing Address - City:PIGEON FORGE
Mailing Address - State:TN
Mailing Address - Zip Code:37863-3423
Mailing Address - Country:US
Mailing Address - Phone:865-453-1924
Mailing Address - Fax:865-453-1926
Practice Address - Street 1:3342 PARKWAY
Practice Address - Street 2:
Practice Address - City:PIGEON FORGE
Practice Address - State:TN
Practice Address - Zip Code:37863-3423
Practice Address - Country:US
Practice Address - Phone:865-453-1924
Practice Address - Fax:865-453-1926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTNMD14371170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP50426Medicare UPIN
TNA96719Medicare UPIN
TN3096659Medicare ID - Type Unspecified