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NPI Code Detail

MEDICARE: DR. MARK JOSEPH DALLE-AVE M.D.

MEDICARE: DR. MARK JOSEPH DALLE-AVE M.D.
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
1207Q00000XFamily Medicine Physician25875TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
14057107OTHERTNBCBST
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1801892054
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MARK JOSEPH DALLE-AVE M.D.
Provider Business Mailing Address
First Line : PO BOX 850
Second Line :
City : ROGERSVILLE
State : TN
Zip : 37857-0850
Country : US
Telephone Number : 423-272-5202
Fax Number : 423-272-4696
Provider Business Practice Location Address
First Line : 4307 HIGHWAY 66 S
Second Line :
City : ROGERSVILLE
State : TN
Zip : 37857-3155
Country : US
Telephone Number : 423-921-1600
Fax Number : 423-921-1677
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/22/2005
Last Update Date : 02/28/2014

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