Healthcare Provider Details

I. General information

NPI: 1093760902
Provider Name (Legal Business Name): INTERNAL MEDICINE AND PEDIATRIC ASSOC OF BRISTOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 STEELES ROAD
BRISTOL TN
37620-9532
US

IV. Provider business mailing address

350 STEELES RD STE 2
BRISTOL TN
37620-9532
US

V. Phone/Fax

Practice location:
  • Phone: 423-844-6700
  • Fax: 423-844-6703
Mailing address:
  • Phone: 423-844-6700
  • Fax: 866-334-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateTN

VIII. Authorized Official

Name: VICKI L MOODY
Title or Position: PRACTICE EXECUTIVE
Credential:
Phone: 423-844-6704