MEDICARE: SOUTHWELL MEDICAL LLC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213EP1101X	Primary Podiatric Medicine Podiatrist
2	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1003520966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWELL MEDICAL LLC.

Provider Business Mailing Address
First Line	:	207 LAKE FOREST DR
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37920-5144
Country	:	US
Telephone Number	:	865-455-4817
Fax Number	:

Provider Business Practice Location Address
First Line	:	207 LAKE FOREST DR
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37920-5144
Country	:	US
Telephone Number	:	865-455-4817
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JAKE HARRISON
Credential	:	FNP
Telephone Number	:	865-455-4817

Provider Enumeration Date	:	01/05/2023
Last Update Date	:	01/05/2023

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Directions to “SOUTHWELL MEDICAL LLC. ” Practice Location

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