Provider Demographics
NPI:1699068494
Name:MERCY PRIMARY CARE WEST
Entity type:Organization
Organization Name:MERCY PRIMARY CARE WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-549-4892
Mailing Address - Street 1:10810 PARKSIDE DRIVE SUITE G11
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10810 PARKSIDE DR STE G11
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1979
Practice Address - Country:US
Practice Address - Phone:865-777-2727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY PHYSICIAN SERVIES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3373630Medicare PIN