Healthcare Provider Details

I. General information

NPI: 1316970742
Provider Name (Legal Business Name): INGRID KJELLIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 CADILLAC DR STE 200
BRENTWOOD TN
37027-5087
US

IV. Provider business mailing address

308 N PETERS RD STE 225
KNOXVILLE TN
37922-2327
US

V. Phone/Fax

Practice location:
  • Phone: 615-376-7360
  • Fax:
Mailing address:
  • Phone: 865-694-0062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA50153
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number42987
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.093097
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01064511A
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036122003
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2010-00424
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: